Clinical significance of the anti-Nucleolar Organizer Region 90 antibodies (NOR90) in systemic sclerosis: Analysis of the European Scleroderma Trials and Research (EUSTAR) cohort and a systematic literature review

BACKGROUND

The anti-Nucleolar Organizer Region 90 antibodies (NOR90) are rare antinuclear antibodies (ANA) reported in systemic sclerosis (SSc). Especially due to low prevalence, the clinical relevance of NOR90 in SSc remains uncertain.

OBJECTIVES

To analyze the clinical associations of NOR90 in patients with SSc in a multicentric cohort.

METHODS

Post-hoc, cross-sectional study of prospectively collected data from the European Scleroderma Trials and Research (EUSTAR) database, with additional information on NOR90. Further, we performed a systematic literature search, using the terms "systemic sclerosis" and "NOR90" across three databases: Medline via PubMed, Scopus, and Thomson Reuters' Web of Science Core Collection, from inception to November 1st, 2023.

RESULTS

Overall, 1318 patients with SSc were included (mean age 58.3 ± 13.7 years, 81.3 % female), of whom 44 (3.3 %) were positive for NOR90. Of these, 32 were also positive for one of the SSc-criteria antibodies: 9/44 (20.5 %) for anti-topoisomerase I, 18/42 (42.9 %) for anti-centromere, and 5/40 (12.5 %) for anti-RNA polymerase III. NOR90-positive patients were more frequently female, had lower modified Rodnan skin score (mRSS), and lower prevalence of upper and lower gastrointestinal (GI) symptoms compared to NOR90-negative patients. In multivariable analysis, NOR90 remained significantly associated with lower mRSS and less frequent GI symptoms. The literature search identified 17 articles, including a total number of 87 NOR90-positive out of 3357 SSc patients, corresponding to an overall prevalence of 2.6 %.

CONCLUSION

To our best knowledge, this is the largest SSc cohort tested for NOR90 to date, confirming the NOR90 prevalence in SSc patients is around 3 %.

Low back pain patients with Modic type 1 changes exhibit distinct bacterial and non-bacterial subtypes

Objectives

Modic type 1 changes (MC1) are vertebral endplate bone marrow (BM) lesions observed on magnetic resonance images in sub-populations of chronic low back pain (CLBP) patients. The etiopathogenesis remains unknown and treatments that modify the underlying pathomechanisms do not exist. We hypothesized that two biological MC1 subtypes exist: a bacterial and a non-bacterial. This would have important implications for developing treatments targeting the underlying pathomechanisms.

Methods

Intervertebral disc (IVD) samples adjacent to MC1 (n ​= ​34) and control (n ​= ​11) vertebrae were collected from patients undergoing spinal fusion. Cutibacterium acnes (C.acnes) genome copy numbers (GCNs) were quantified in IVD tissues with 16S qPCR, transcriptomic signatures and cytokine profiles were determined in MC1 and control BM by RNA sequencing and immunoassay. Finally, we assessed if C.acnes GCNs are associated with blood plasma cytokines.

Results

IVD tissues from control levels had <870 ​C.acnes GCNs/gram IVD. MC1-adjacent IVDs had either "low" (<870) or "high" (>870) C.acnes GCNs. MC1 patients with "high" C.acnes GCNs had upregulated innate immune cell signatures (neutrophil, macrophage/monocyte) and pro-inflammatory cytokines related to neutrophil and macrophage/monocyte function in the BM, consistent with a host defense against bacterium. MC1 patients with "low" C.acnes GCNs had increased adaptive immune cell signatures (T-and B-cell) in the BM and elevated IL-13 blood plasma levels.

Conclusion

Our study provides the first evidence for the existence of bacterial (C.acnes "high") and non-bacterial (C.acnes "low") subtypes in MC1 patients with CLBP. This supports the need for different treatment strategies.

FGF2 overrides key pro-fibrotic features of bone marrow stromal cells isolated from Modic type 1 change patients

Extensive extracellular matrix production and increased cell-matrix adhesion by bone marrow stromal cells (BMSCs) are hallmarks of fibrotic alterations in the vertebral bone marrow known as Modic type 1 changes (MC1). MC1 are associated with non-specific chronic low-back pain. To identify treatment targets for MC1, in vitro studies using patient BMSCs are important to reveal pathological mechanisms. For the culture of BMSCs, fibroblast growth factor 2 (FGF2) is widely used. However, FGF2 has been shown to suppress matrix synthesis in various stromal cell populations. The aim of the present study was to investigate whether FGF2 affected the in vitro study of the fibrotic pathomechanisms of MC1-derived BMSCs. Transcriptomic changes and changes in cell-matrix adhesion of MC1-derived BMSCs were compared to intra-patient control BMSCs in response to FGF2. RNA sequencing and quantitative real-time polymerase chain reaction revealed that pro-fibrotic genes and pathways were not detectable in MC1-derived BMSCs when cultured in the presence of FGF2. In addition, significantly increased cell-matrix adhesion of MC1-derived BMSCs was abolished in the presence of FGF2. In conclusion, the data demonstrated that FGF2 overrides key pro-fibrotic features of MC1 BMSCs in vitro. Usage of FGF2-supplemented media in studies of fibrotic mechanisms should be critically evaluated as it could override normally dominant biological and biophysical cues.

POS0385 “EFFECTIVE LUNG AGE” IN SUBJECTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE (SSc-ILD) IN THE SENSCIS TRIAL

Background

FVC declines gradually with aging. The loss of lung function in patients with progressive SSc-ILD mimics an accelerated ageing process.

Objectives

Using reference equations, we estimated the “effective lung age” of subjects in the SENSCIS trial (i.e. the age of healthy individuals with the same FVC) and compared these estimates to their real age.

Methods

The SENSCIS trial enrolled subjects with SSc-ILD with first non-Raynaud symptom within the prior ≤7 years, extent of fibrotic ILD on HRCT ≥10%, FVC ≥40% predicted, DLco 30–89% predicted. Evidence of recent decline in FVC was not an inclusion criterion. Subjects were randomised to receive nintedanib or placebo. Using reference equations published by the European Respiratory Society Global Lung Function Initiative, based on FVC data from over 70,000 healthy individuals aged 3–95 years from 26 countries, [Quanjer et al. Eur Respir J 2012;40:1324–1343], we estimated the effective lung age of subjects at baseline and at week 52 based on their FVC, sex, ethnicity and height, and compared these effective lung ages with the subjects’ real ages. Three subjects aged <25 years were excluded. The upper limit of effective lung age was considered to be 95 years.

Results

Mean time since onset of first non-Raynaud symptom was 3.5 years in both the nintedanib and placebo groups. At baseline, mean (SD) effective lung age was 83.1 (14.4) years in the nintedanib group (n=287) and 82.9 (14.8) years in the placebo group (n=286). In these groups, respectively, the mean (SD) difference between effective lung age and real age was 28.4 (17.7) and 29.3 (18.5) years and the difference was >20 years in 71.4% and 72.4% of subjects. In the nintedanib and placebo groups, respectively, median (Q1, Q3) effective lung age was 88.4 (74.6, 95.0) and 88.5 (74.7, 95.0) years at baseline and 91.0 (75.2, 95.0) and 95.0 (75.9, 95.0) years at week 52.

Conclusion

At entry into the SENSCIS trial, subjects with SSc-ILD had an effective lung age that was much higher than their real age. Over 52 weeks, the increase in effective lung age was numerically lower in subjects treated with nintedanib than placebo. These data show that marked loss of lung function that can occur in the few years following onset of SSc-ILD and support a benefit of nintedanib in slowing the progression of SSc-ILD.

Acknowledgements

The SENSCIS trial was funded by Boehringer Ingelheim. Toby M Maher and Oliver Distler were members of the SENSCIS trial Steering Committee.

Disclosure of Interests

Toby Maher Speakers bureau: Boehringer Ingelheim, Galapagos, Genentech, Consultant of: AstraZeneca, Bayer, Blade Therapeutics, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Galecto, GlaxoSmithKline R&D, IQVIA, Pliant, Respivant, Roche, Theravance and Veracyte, Grant/research support from: AstraZeneca, GlaxoSmithKline, Arnaud Bourdin Speakers bureau: Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Regeneron, Sanofi, Paid instructor for: Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Regeneron, Sanofi, Consultant of: Amgen, AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Novartis, Regeneron, Sanofi, Grant/research support from: AstraZeneca and Boehringer Ingelheim, Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, Corbus, Forbius, Horizon, Kadmon, Serena Vettori Consultant of: Boehringer Ingelheim, Jörg H.W. Distler Shareholder of: 4D Science, Speakers bureau: Boehringer Ingelheim, Inventiva, Janssen, and UCB, Consultant of: AbbVie, Active Biotech, Anamar, ARXX, AstraZeneca, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GlaxoSmithKline, Inventiva, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: Anamar, ARXX, Bristol-Myers Squibb, Bayer Pharma, Boehringer Ingelheim, Cantargia, Celgene, CSL Behring, Galapagos, GlaxoSmithKline, Inventiva, Kiniksa, Sanofi-Aventis, RedX, UCB, Margarida Alves Employee of: Margarida Alves is an employee of Boehringer Ingelheim, Christian Stock Employee of: Christian Stock is an employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

POS0855 IMPAIRED PROMIS PHYSICAL FUNCTION IN IDIOPATHIC INFLAMMATORY MYOPATHY PATIENTS: RESULTS FROM THE MULTICENTER COVAD PATIENT REPORTED E-SURVEY

Background

Evaluation of physical function is fundamental in the management of idiopathic inflammatory myopathies (IIMs). Patient-Reported Outcome Measurement Information System (PROMIS) is a National Institute of Health initiative established in 2004 to develop patient-reported outcome measures (PROMs) with improved validity and efficacy. PROMIS Physical Function (PF) short forms have been validated for use in IIMs [1].

Objectives

To investigate the physical function status of IIM patients compared to those with non-IIM autoimmune diseases (AIDs) and healthy controls (HCs) utilizing PROMIS PF data obtained in the coronavirus disease-2019 (COVID-19) Vaccination in Autoimmune Diseases (COVAD) study, a large-scale, international self-reported e-survey assessing the safety of COVID-19 vaccines in AID patients [2].

Methods

The survey data regarding demographics, IIM and AID diagnosis, disease activity, and PROMIS PF short form-10a scores were extracted from the COVAD study database. The disease activity (active vs inactive) of each patient was assessed in 3 different ways: (1) physician’s assessment (active if there was an increased immunosuppression), (2) patient’s assessment (active vs inactive as per patient), and (3) current steroid use. These 3 definitions of disease activity were applied independently to each patient. PROMIS PF-10a scores were compared between each disease category (IIMs vs non-IIM AIDs vs HCs), stratified by disease activity based on the 3 definitions stated above, employing negative binominal regression model. Multivariable regression analysis adjusted for age, gender, and ethnicity was performed clustering countries, and the predicted PROMIS PF-10a score was calculated based on the regression result. Factors affecting PROMIS PF-10a scores other than disease activity were identified by another multivariable regression analysis in the patients with inactive disease (IIMs or non-IIM AIDs).

Results

1057 IIM patients, 3635 non-IIM AID patients, and 3981 HCs responded to the COVAD survey until August 2021. The median age of the respondents was 43 [IQR 30-56] years old, and 74.8% were female. Among IIM patients, dermatomyositis was the most prevalent diagnosis (34.8%), followed by inclusion body myositis (IBM) (23.6%), polymyositis (PM) (16.2%), anti-synthetase syndrome (11.8%), overlap myositis (7.9%), and immune-mediated necrotizing myopathy (IMNM) (4.6%). The predicted mean of PROMIS PF-10a scores was significantly lower in IIMs compared to non-IIM AIDs or HCs (36.3 [95% (CI) 35.5-37.1] vs 41.3 [95% CI 40.2-42.5] vs 46.2 [95% CI 45.8-46.6], P < 0.001), irrespective of disease activity or the definitions of disease activity used (physician’s assessment, patient’s assessment, or steroid use) (Figure 1). The largest difference between active IIMs and non-IIM AIDs was observed when the disease activity was defined by patient’s assessment (35.0 [95% CI 34.1-35.9] vs 40.1 [95% CI 38.7-41.5]). Considering the subgroups of IIMs, the scores were significantly lower in IBM in comparison with non-IBM IIMs (P < 0.001). The independent factors associated with low PROMIS PF-10a scores in the patients with inactive disease were older age, female gender, and the disease category being IBM, PM, or IMNM.

Conclusion

Physical function is significantly impaired in IIMs compared to non-IIM AIDs or HCs, even in patients with inactive disease. The elderly, women, and IBM groups are the worst affected, suggesting that developing targeted strategies to minimize functional disability in certain groups may improve patient reported physical function and disease outcomes.

References

[1]Saygin D, Oddis CV, Dzanko S, et al. Utility of patient-reported outcomes measurement information system (PROMIS) physical function form in inflammatory myopathy. Semin Arthritis Rheum. 2021; 51: 539-46.

[2]Sen P, Gupta L, Lilleker JB, et al. COVID-19 vaccination in autoimmune disease (COVAD) survey protocol. Rheumatol Int. 2022; 42: 23-9.

Acknowledgements

The authors thank all respondents for filling the questionnaire. The authors thank The Myositis Association, Myositis India, Myositis UK, the Myositis Global Network, Cure JM, Cure IBM, Sjögren’s India Foundation, EULAR PARE, and various other patient support groups and organizations for their invaluable contribution in the dissemination of this survey among patients which made the data collection possible. The authors also thank all members of the COVAD study group.

Disclosure of Interests

None declared

POS0899 HIGH FATIGUE SCORES IN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOPATHIES: A MULTIGROUP COMPARATIVE STUDY FROM THE COVAD E-SURVEY

Background

Idiopathic inflammatory myopathies (IIM) are a rare, multisystem, heterogeneous diseases, and contribute to high psychological burden. The patients’ perception of physical health, deteriorating independence and social and environmental relationships may not always be a direct function of disease activity. To face with these aspects, several worldwide specialized organization have recommended the use of patient reported outcome measures (PROMs) both in clinical trials and observational studies to highlight patient’s perception of the disease (1). Unfortunately, data on fatigue scores in IIM is limited.

Objectives

We compared fatigue VAS scores in patients with IIM, autoimmune diseases (AIDs) and healthy controls (HCs) and triangulated them with PROMIS physical function in a large international cohort made up of answers from the e-survey regarding the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study.

Methods

Data of 16327 respondents was extracted from the COVAD database on August 31th 2021. VAS fatigue scores were compared between AID, HC and IIM using univariate followed by multivariate analysis after adjusting for baseline differences. We further performed a propensity score matched analysis on 1827 subjects after adjusting for age, gender and ethnicity. The Kruskal-Wallis test was used for continuous variables and chi-square test for categorical variables, and Bonferroni’s correction was applied for the post hoc analyses considering IIMs as a reference group.

Results

We analyzed answers from 6988 patients, with a mean age of 43.8 years (SD 16.2). The overall percentage of female was 72% and the population ethnicity was mainly composed of White (55.1%), followed by Asian (24.6%), and Hispanic (13.8%). The overall fatigue VAS was 3.6 mm (SD 2.7). IIMs VAS was 4.8 mm (SD 2.6), AIDs 4.5 mm (SD 2.6), and HC 2.8 mm (SD 2.6) (P <0,001). VAS fatigue scores of IIMs were comparable with AIDs (P 0.084), albeit significantly higher than the HCs (P <0,001). Notably, fatigue VAS was lower in IIMs than AIDs in two distinct subsets: inactive disease as defined by the patient’s perception and the “excellent” general health condition group, where IIMs had worse scores (P <0,05). Interestingly, fatigue VAS was comparable in active disease defined by physician assessment, patient perception, based on general functional status, or when defined by steroid dose being prescribed. Notably, after propensity matched analysis of patients adjusting for gender, age and ethnicity (1.827 answers, i.e. 609 subjects per group, P =1) the differences disappeared and IIMs and AIDs had comparable fatigue levels across all levels of disease activity, although the fatigue discrepancies with HCs were substantially confirmed.

After application of a multivariate linear regression analysis we found that lower fatigue VAS scores were related to HC (P <0,001), male gender (P <0,001), Asian and Hispanic ethnicities (P <0,001 and 0,003).

Conclusion

Our study confirms that there is a higher prevalence of fatigue in all the AIDs patients, with comparable VAS scores between IIMs and other AIDs. We can also read our data commenting that females and/or Caucasians patients suffer a higher impact of this manifestation of chronic autoimmune diseases upon their lives. This is why these subjects, to our judgement, should be carefully evaluated during outpatients visits and to whom we should spend some extra time to discuss health related issues and how to improve them.

References

[1]Regardt, M. et al. OMERACT 2018 Modified Patient-reported Outcome Domain Core Set in the Life Impact Area for Adult Idiopathic Inflammatory Myopathies. J. Rheumatol.46, 1351–1354 (2019).

Figure 1.

distribution of Fatigue VAS scores in the three population evaluated. IIM idiopathic inflammatory myositis; AID autoimmune diseases; HC healthy controls; * P < 0,05.

Disclosure of Interests

None declared

POS1260 COVID-19 VACCINATION-RELATED ADVERSE EVENTS AMONG AUTOIMMUNE DISEASE PATIENTS: RESULTS FROM THE COVID-19 VACCINATION IN AUTOIMMUNE DISEASES (COVAD) STUDY

Background

COVID-19 vaccines have been proven to be safe and effective in the healthy population at large. However, significant gaps remain in the evidence of their safety in patients with systemic autoimmune and inflammatory disorders (SAIDs). Patients and rheumatologists have expressed concerns regarding vaccination triggered allergic reactions, thrombogenic events, and other adverse events (ADEs) contributing to vaccine hesitancy (1)

Objectives

This study aimed to assess and compare short term COVID-19 vaccination associated ADEs in patients with SAIDs and healthy controls (HC) seven days post-vaccination, as well as between patients with SAIDs receiving different vaccines.

Methods

We developed an comprehensive, patient self-reporting electronic-survey to collect respondent demographics, SAID details, COVID-19 infection history, COVID-19 vaccination details, 7-day post vaccination adverse events and patient reported outcome measures using the PROMIS tool. After pilot testing, validation, translation into 18 languages on the online platform surveymonkey.com, and vetting by international experts, the survey was circulated in early 2021 by a multicenter study group of >110 collaborators in 94 countries. ADEs were categorized as injection site pain, minor ADEs, major ADEs, and hospitalizations. We analyzed data from the baseline survey for descriptive and intergroup comparative statistics based on data distribution and variable type (data as median, IQR).

Results

10900 respondents [42 (30-55) years, 74% females and 45% Caucasians] were analyzed. 5,867 patients (54%) with SAIDs were compared with 5033 HCs. All respondents included in the final analysis had received a single dose of the vaccine and 69% had received 2 primary doses. Pfizer (39.8%) was the most common vaccine received, followed by Oxford/AstraZeneca (13.4%), and Covishield (10.9%). Baseline demographics differed by an older SAID population (mean age 42 vs. 33 years) and a greater female predominance (M:F= 1:4.7 vs. 1:1.8) compared to HCs.

79% had minor and only 3% had major vaccine ADEs requiring urgent medical attention overall. In adjusted analysis, among minor ADEs, abdominal pain [multivariate OR 1.6 (1.14-2.3)], dizziness [multivariate OR 1.3 (1.2-1.5)], and headache [multivariate OR 1.67 (1.3-2.2)], were more frequent in SAIDs than HCs. Overall major ADEs [multivariate OR 1.9 (1.6-2.2)], and throat closure [multivariate OR 5.7 (2.9-11.3)] were more frequent in SAIDs though absolute risk was small (0-4%) and rates of hospitalization were similarly small in both groups, with a small absolute risk (0-4%). Specific minor ADEs frequencies were different among different vaccine types, however, major ADEs and hospitalizations overall were rare (0-4%) and comparable across vaccine types in patients with SAIDs (Figure 1).

Figure 1.

A. Post Vaccination ADEs in SAIDs compared to HCs. B. Proportions of post COVID-19 vaccination ADEs in SAIDs by vaccine type.

Conclusion

Vaccination against COVID-19 is relatively safe and tolerable in patients with SAIDs. Certain minor vaccine ADEs are more frequent in SAIDs than HCs in this study, though are not severe and do not require urgent medical attention. SAIDs were at a higher risk of major ADEs than HCs, though absolute risk was small, and did not lead to increased hospitalizations. There are small differences in minor ADEs between vaccine types in patients with SAIDs.

References

[1]Boekel L, Kummer LY, van Dam KPJ, Hooijberg F, van Kempen Z, Vogelzang EH, et al. Adverse events after first COVID-19 vaccination in patients with autoimmune diseases. Lancet Rheumatol. 2021 Aug;3(8):e542–5.

Acknowledgements

The authors thank all members of the COVAD study group for their invaluable role in the collection of data. The authors thank all respondents for filling the questionnaire. The authors thank The Myositis Association, Myositis India, Myositis UK, the Myositis Global Network, Cure JM, Cure IBM, Sjögren’s India Foundation, EULAR PARE, and various other patient support groups and organizations for their invaluable contribution in the dissemination of this survey among patients which made the data collection possible. The authors also thank all members of the COVAD study group.

Disclosure of Interests

Parikshit Sen: None declared, Naveen R: None declared, Arvind Nune: None declared, James B. Lilleker: None declared, Vishwesh Agarwal: None declared, Sinan Kardes: None declared, Minchul Kim: None declared, Jessica Day Grant/research support from: JD has received research funding from CSL Limited., Marcin Milchert: None declared, Tamer A Gheita: None declared, Babur Salim: None declared, Tsvetelina Velikova: None declared, Abraham Edgar Gracia-Ramos: None declared, Ioannis Parodis Speakers bureau: IP has received research funding and/or honoraria from Amgen, AstraZeneca, Aurinia Pharmaceuticals, Elli Lilly and Company, Gilead Sciences, GlaxoSmithKline, Janssen Pharmaceuticals, Novartis and F. Hoffmann-La Roche AG., Consultant of: IP has received research funding and/or honoraria from Amgen, AstraZeneca, Aurinia Pharmaceuticals, Elli Lilly and Company, Gilead Sciences, GlaxoSmithKline, Janssen Pharmaceuticals, Novartis and F. Hoffmann-La Roche AG., Grant/research support from: IP has received research funding and/or honoraria from Amgen, AstraZeneca, Aurinia Pharmaceuticals, Elli Lilly and Company, Gilead Sciences, GlaxoSmithKline, Janssen Pharmaceuticals, Novartis and F. Hoffmann-La Roche AG., Albert Selva-O’Callaghan: None declared, Elena Nikiphorou Speakers bureau: EN has received speaker honoraria/participated in advisory boards for Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Consultant of: EN has received speaker honoraria/participated in advisory boards for Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Grant/research support from: EN has received speaker honoraria/participated in advisory boards for Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, and holds research grants from Pfizer and Lilly., Tulika Chatterjee: None declared, Ai Lyn Tan Speakers bureau: ALT has received honoraria for advisory boards and speaking for Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB., Consultant of: ALT has received honoraria for advisory boards and speaking for Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB., Grant/research support from: ALT has received honoraria for advisory boards and speaking for Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB., Lorenzo Cavagna: None declared, Miguel A Saavedra: None declared, Samuel Katsuyuki Shinjo: None declared, Nelly Ziade Speakers bureau: NZ has received speaker fees, advisory board fees and research grants from Pfizer, Roche, Abbvie, Eli Lilly, NewBridge, Sanofi-Aventis, Boehringer Ingelheim, Janssen, Pierre Fabre; none is related to this manuscript., Consultant of: NZ has received speaker fees, advisory board fees and research grants from Pfizer, Roche, Abbvie, Eli Lilly, NewBridge, Sanofi-Aventis, Boehringer Ingelheim, Janssen, Pierre Fabre; none is related to this manuscript., Grant/research support from: NZ has received speaker fees, advisory board fees and research grants from Pfizer, Roche, Abbvie, Eli Lilly, NewBridge, Sanofi-Aventis, Boehringer Ingelheim, Janssen, Pierre Fabre; none is related to this manuscript., Johannes Knitza: None declared, Masataka Kuwana: None declared, Oliver Distler Speakers bureau: OD has/had consultancy relationship with and/or has received research funding from or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Mitsubishi Tanabe, Novartis, Roche, Roivant, Sanofi, Serodapharm, Topadur and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: OD has/had consultancy relationship with and/or has received research funding from or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Mitsubishi Tanabe, Novartis, Roche, Roivant, Sanofi, Serodapharm, Topadur and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: OD has/had consultancy relationship with and/or has received research funding from or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Mitsubishi Tanabe, Novartis, Roche, Roivant, Sanofi, Serodapharm, Topadur and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Hector Chinoy Speakers bureau: HC has served as a speaker for UCB, Biogen., Consultant of: HC has received consulting fees from Novartis, Eli Lilly, Orphazyme, Astra Zeneca, Grant/research support from: HC has received grant support from Eli Lilly and UCB, Vikas Agarwal: None declared, Rohit Aggarwal Consultant of: RA has/had a consultancy relationship with and/or has received research funding from for the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, Kyverna, Janssen, Roivant, Boehringer Ingelheim, Argenx, Q32, Alexion, EMD Serono, Jubliant, Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant., Grant/research support from: RA has/had a consultancy relationship with and/or has received research funding from for the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, Kyverna, Janssen, Roivant, Boehringer Ingelheim, Argenx, Q32, Alexion, EMD Serono, Jubliant, Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant., Latika Gupta: None declared

POS0470 FOSL-2 TRANSCRIPTION FACTOR REGULATES MACROPHAGE POLARIZATION AND PHAGOCYTOSIS IN SYSTEMIC SCLEROSIS

Background

Macrophages play a crucial role in the development and progression of systemic sclerosis (SSc). Pathological effects of the AP-1 transcription factor Fos-related antigen 2 (Fosl-2) have been associated with SSc. However, the exact role of Fosl-2 in macrophage function in SSc has not been clarified.

Objectives

To study macrophage functions in SSc with a focus on Fosl-2 as a potential regulator.

Methods

Human monocyte-derived macrophages (hMDM) were differentiated from CD14+ blood-derived monocytes from healthy controls and SSc patients. Published data of single cell RNA sequencing (scRNAseq) of human explanted lung tissue from SSc-ILD patients1 and skin from dcSSc patients2 was further analyzed using the R package Seurat V2.3.4. Peritoneal macrophages were isolated from Fosl2 overexpressing transgenic (Fosl2tg), Csf1RCreFosl2fl/fl, wild-type (wt) and Fosl2fl/fl mice. Protein expression was detected by Western Blot. Phagocytic activity in hMDM was detected using pHrodo Red E.coli particles and in vivo phagocytosis of phagocytic dye aggregates in peritoneal macrophages was assessed 4 hours post injection and detected by flow cytometry. Surface marker expression was measured using human or mouse macrophage polarization panels by flow cytometry.

Results

SSc hMDM (n=18-25) showed increased Fosl-2 protein expression (untreated: p<0.01, LPS stimulated: p<0.01) compared to healthy hMDM (n=11-18). Phenotypical characterization of untreated SSc hMDM (n=17) displayed an increased percentage of CD40+CD86+CD206+PD-L2+CD163+ cells (p<0.05) compared to healthy hMDM (n=7). Additionally, we found enhanced phagocytic activity in untreated (p<0.01) and LPS stimulated (p<0.05) SSc hMDM (n=29-34) compared to healthy hMDM (n=12-16). To assess the role of Fosl-2 in other macrophage types, we performed scRNAseq analysis of the SSc-ILD lung dataset, which lead to the identification of differentially expressed macrophage polarization (CD206) and phagocytosis-associated genes (MARCO/C1QA/C1QB/C1QC) in SPP1hi macrophages from SSc-ILD patients when comparing FOSL2hi and FOSL2null cells. Moreover, independent of FOSL2 expression phagocytosis-associated ARPC1B/ARPC2/ARPC5 genes were upregulated in SPP1hi, FABP4hi and FCN1hi macrophages in SSc-ILD patients (p.adj.≤0.05; log2 ratio≥0.5). Similarly, to the alternatively-activated macrophages in SSc-ILD lungs, scRNAseq of dcSSc skin tissue revealed increased expression of CD204/CD163/CD36 in CCR1+ macrophages. Further, FOSL2hi CCR1+ skin macrophages showed higher expression of phagolysosome-associated CARO1A and ARL8B genes compared to FOSL2null cells (p.adj.≤0.05; log2 ratio≥0.5).

In the immunofibrotic animal model of SSc, Fosl2tg peritoneal macrophages showed enhanced expression of alternatively-activated CD206 (p=0.0591) and PD-L2 (p<0.05) polarization markers compared to wt cells (n=5-9). Csf1RCreFosl2fl/fl peritoneal macrophages displayed a reduced expression of CD206 (p<0.05) and PD-L2 (p<0.01) markers compared to Fosl2fl/fl controls (n=5-9). Preliminary data indicated that Fosl2tg MHCII+ and CD36+ peritoneal macrophages showed a trend towards elevated phagocytic activity compared to wt cells (n=3). Csf1RCreFosl2fl/fl peritoneal macrophages did not show a significant difference in phagocytic activity (n=3) compared to Fosl2fl/fl controls.

Conclusion

For the first time, we showed an increased expression of Fosl-2 and boosted phagocytic activity in SSc hMDM. scRNAseq analyses revealed upregulated phagocytosis-related genes with association to alternatively-activated macrophage polarization in different macrophage clusters in SSc-ILD lungs and dcSSc skin. Moreover, our animal data indicated an involvement of Fosl-2 regulating alternatively-activated macrophage polarization and phagocytosis. Therefore, targeting this alternative/pro-phagocytic phenotype represents an effective tool to counteract disease progression.

References

[1]Valenzi, E., et al., Ann Rheum Dis, 2019

[2]Xue, D., et al., Arthritis Rheumatol, 2022

Disclosure of Interests

Amela Hukara: None declared, Tracy Tabib: None declared, Michal Rudnik: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Przemyslaw Blyszczuk: None declared, Robert Lafyatis Consultant of: Pfizer, Bristol Myers Squibb, Boehringer-Ingleheim, Formation, Sanofi, Boehringer-Mannheim, Merck and Genentech/Roche, Grant/research support from: Corbus, Formation, Moderna, Regeneron, Pfizer and Kiniksa, Gabriela Kania: None declared.

AB0657 Severity and impact of gastrointestinal symptoms in patients with SSc-ILD treated with nintedanib: data from SENSCIS-ON

Background

Gastrointestinal (GI) involvement is a common manifestation of systemic sclerosis (SSc) and a frequent side-effect of drugs used to treat SSc. In the SENSCIS trial, nintedanib reduced the rate of decline in forced vital capacity (FVC) in patients with SSc-associated interstitial lung disease (SSc-ILD), with an adverse event profile characterised predominantly by GI events.

Objectives

To assess the severity and impact of GI symptoms on quality of life in patients treated with nintedanib in the open-label extension trial, SENSCIS-ON.

Methods

Patients with SSc-ILD who completed the SENSCIS trial or a drug–drug interaction (DDI) study of nintedanib and oral contraceptive were eligible to enter SENSCIS-ON. Patients who received nintedanib in SENSCIS (up to 100 weeks) and continued nintedanib in SENSCIS-ON comprised the “continued nintedanib” group. Patients who received placebo in SENSCIS and initiated nintedanib in SENSCIS-ON, or who received nintedanib for a short time in the DDI study, comprised the “initiated nintedanib” group. We assessed changes in scores on the UCLA Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA SCTC GIT) questionnaire v2.0 from baseline to week 52. This questionnaire comprises 7 scales measuring the severity and impact of GI symptoms: reflux, distension or bloating, faecal soilage, diarrhoea, constipation, emotional well-being, social functioning. Each scale is scored from 0 to 3 except for the diarrhoea scale (0 to 2) and constipation scale (0 to 2.5). The total score, the mean of the scores for the scales except constipation, ranges from 0 to 2.83, with higher scores indicating worse symptoms.

Results

The “continued nintedanib” group comprised 197 patients and the “initiated nintedanib” group comprised 247 patients (231 from SENSCIS). Of these, 178 and 218 patients, respectively, provided a total UCLA SCTC GIT score at baseline. At baseline, mean (SD) total scores were 0.33 (0.33) and 0.33 (0.34) in the continued nintedanib and initiated nintedanib groups, respectively. Mean (SD) scores on the 7 scales ranged from 0.16 (0.52) to 0.70 (0.73) in the continued nintedanib group and from 0.13 (0.43) to 0.64 (0.68) in the initiated nintedanib group. Increases (worsening) in scores were observed in both groups from baseline to week 52, except for on the constipation scale (Figure 1). Based on the total score, between baseline and week 52, the proportion of patients with moderate or severe or very severe GI symptoms increased, but 45.7% and 39.7% of patients in the continued nintedanib and initiated nintedanib groups, respectively, had no or mild GI symptoms at week 52 (Table 1).

Table 1.

Changes in severity and impact of gastrointestinal symptoms based on UCLA SCTC GIT total score between baseline and week 52 of SENSCIS-ON

BaselineWeek 52None or mildModerateSevere or very severeMissingTotalContinued nintedanibNone or mild81 (41.1)5 (2.5)04 (2.0)90 (45.7)Moderate38 (19.3)10 (5.1)01 (0.5)49 (24.9)Severe or very severe13 (6.6)14 (7.1)7 (3.6)1 (0.5)35 (17.8)Missing6 (3.0)3 (1.5)1 (0.5)13 (6.6)23 (11.7)Total138 (70.1)32 (16.2)8 (4.1)19 (9.6)197 (100)Initiated nintedanibNone or mild87 (35.2)6 (2.4)1 (0.4)4 (1.6)98 (39.7)Moderate35 (14.2)12 (4.9)2 (0.8)3 (1.2)52 (21.1)Severe or very severe8 (3.2)7 (2.8)4 (1.6)1 (0.4)20 (8.1)Missing37 (15.0)15 (6.1)4 (1.6)21 (8.5)77 (31.2)Total167 (67.6)40 (16.2)11 (4.5)29 (11.7)247 (100)

Data are n (%) of patients. None or mild=scores of 0 to 0.49; moderate=scores of 0.5 to 1; severe or very severe=scores of 1.01 to 3.

Figure 1.

Changes in UCLA SCTC GIT scores from baseline to week 52 of SENSCIS-ON

Conclusion

In the SENSCIS-ON trial, the majority of patients with SSc-ILD treated with nintedanib had no or mild GI symptoms at baseline. A small worsening in GI symptoms was observed over 52 weeks. Diarrhoea had the greatest impact, reflecting the adverse event profile of nintedanib. Recommendations for the management of diarrhoea in patients treated with nintedanib should be implemented in clinical practice.

Acknowledgements

The SENSCIS-ON trial was funded by Boehringer Ingelheim.

Disclosure of Interests

Dinesh Khanna Shareholder of: Eicos Sciences, Inc - stocks, Consultant of: AbbVie, Acceleron, Actelion, Amgen, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos NV, Genentech/Roche, Gilead, GlaxoSmithKline, Horizon Therapeutics, Merck Sharp & Dohme, Mitsubishi Tanabe Pharma, Sanofi-Aventis, United Therapeutics, Prometheus, Theraly, AstraZeneca, Grant/research support from: Bayer, Bristol-Myers Squibb, Horizon Therapeutics, Immune Tolerance Network, National Institutes of Health, Pfizer, Employee of: CiviBioPharma/Eicos Sciences, Inc - Leadership/Equity position – Chief Medical Officer, Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, Corbus, Forbius, Horizon, Kadmon, Kristin Highland Speakers bureau: Actelion Pharmaceuticals (Jansen), Bayer Healthcare, Boehringer Ingelheim, United Therapeutics, Paid instructor for: Acceleron Pharmaceuticals, Actelion Pharmaceuticals, Bayer Healthcare, Boehringer Ingelheim, Gilead Sciences, United Therapeutics, Consultant of: Boehringer Ingelheim, United Therapeutics, Genentech, Forsee Pharmaceuticals, Grant/research support from: Acceleron Pharmaceuticals, Actelion Pharmaceuticals, Bayer Healthcare, Boehringer Ingelheim, Genentech, Gossamer Bio, Eiger Pharmaceuticlas, Lilly Pharmaceuticals, Reata Pharmaceuticals, United Therapeutics, Viela Bio (Horizon Pharmaceuticals), Yannick Allanore Consultant of: Abbvie, AstraZeneca, Bayer, Boehringer Ingelheim, Janssen, Medsenic, Mylan, Prometheus, Roche, Sanofi, Grant/research support from: Alpine Immunosciences, Medsenic, OSE Immunotherapeutics, Stéphane Jouneau Paid instructor for: Cours, formations - Actelion, AIRB, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, LVL, Mundipharma, Novartis, Pfizer, Roche, Consultant of: Advisory Boards, consultancy - AIRB, Boehringer Ingelheim, Roche, Grant/research support from: Recherche Clinique - AIRB, Biogen, Bristol-Myers Squibb, Boehringer Ingelheim, Galactic, Gilead, LVL, Roche, Savara

Aides pour des recherches - AIRB, Boehringer Ingelheim, LVL, Novartis, Roche, James Seibold Shareholder of: Prometheus Biosciences, Speakers bureau: Boehringer Ingelheim, Consultant of: Alexion, Blade, Camurus AB, GlaxoSmithKline, Prometheus Biosciences, Sironax, Sojournix, Xenikos, Employee of: Prometheus Biosciences, Alexandra James Employee of: Alexandra James is an employee of Elderbrook solutions GmbH that is contracted by Boehringer Ingelheim, Margarida Alves Employee of: Margarida Alves is an employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

AB0658 Nocebo effect on diarrhoea reported in the SENSCIS trial of nintedanib in patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD)

Background

Unfavourable effects observed after administration of placebo that may be attributed to factors such as expectation or conditioning are known as nocebo effects. Prior to initiation of the SENSCIS trial, diarrhoea was a known side-effect of nintedanib.

Objectives

To investigate whether a nocebo effect contributed to reporting of diarrhoea in the SENSCIS trial.

Methods

The SENSCIS trial enrolled patients with systemic sclerosis (SSc) with first non-Raynaud symptom in the prior ≤7 years and ≥10% extent of fibrotic ILD on high-resolution computed tomography. Patients were randomised to receive nintedanib or placebo until the last patient had reached week 52 but for ≤100 weeks. A follow-up visit was conducted 28 days after the end of treatment. Adverse events were reported by investigators irrespective of causality and coded according to the Medical Dictionary for Regulatory Activities. We analysed the incidence of diarrhoea adverse events in the on-treatment period (i.e., events with onset between the first intake of trial drug intake and the last intake plus 7 days) and in the post-discontinuation period (i.e., events with onset between the first day after the on-treatment period and the end of the follow-up period) in the nintedanib and placebo groups. Incidence rates were calculated as the number of patients with diarrhoea adverse events divided by the time at risk.

Results

In the on-treatment period (time at risk: 277.8 patient-years), the rate of diarrhoea adverse events in the placebo group (n=288) was 33.1 per 100 patient-years. In the post-discontinuation period (time at risk: 41.9 patient-years), the rate of diarrhoea adverse events in the placebo group (n=284) was 19.1 per 100 patient-years. In the on-treatment period (time at risk: 105.1 patient-years), the rate of diarrhoea adverse events in the nintedanib group (n=288) was 209.3 per 100 patient-years. In the post-discontinuation period (time at risk: 53.7 patient-years), the rate of diarrhoea adverse events in the nintedanib group (n=283) was 5.6 per 100 patient-years.

Conclusion

In the SENSCIS trial in patients with SSc-ILD, the rate of diarrhoea adverse events in the placebo group fell after trial drug was discontinued. This suggests that a nocebo effect may have contributed to the diarrhoea adverse events reported in the SENSCIS trial.

Acknowledgements

The SENSCIS trial was funded by Boehringer Ingelheim. Oliver Distler, Kristin B Highland and Arata Azuma were members of the SENSCIS trial Steering Committee.

Disclosure of Interests

Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

, Kristin Highland Speakers bureau: Actelion Pharmaceuticals (Jansen), Bayer Healthcare, Boehringer Ingelheim, United Therapeutics, Paid instructor for: Acceleron Pharmaceuticals, Actelion Pharmaceuticals, Bayer Healthcare, Boehringer Ingelheim, Gilead Sciences, United Therapeutics, Consultant of: Boehringer Ingelheim, Forsee Pharmaceuicals, Genentech, United Therapeutics, Grant/research support from: Acceleron Pharmaceuticals, Actelion Pharmaceuticals, Bayer Healthcare, Boehringer Ingelheim, Genentech, Gossamer Bio, Eiger Pharmaceuticlas, Lilly Pharmaceuticals, Reata Pharmaceuticals, United Therapeutics, Viela Bio (Horizon Pharmaceuticals), Arata Azuma Speakers bureau: AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Consultant of: Boehringer Ingelheim, Kyorin Pharma, Taiho Co., Toray Medical Co., Grant/research support from: Boehringer Ingelheim, Taiho Co., Corinna Miede Employee of: Corinna Miede is an employee of mainanalytics GmbH that is contracted by Boehringer Ingelheim, Margarida Alves Employee of: Margarida Alves is an employee of Boehringer Ingelheim, Petros Sfikakis: None declared

POS0482 LONG NON-CODING RNA H19X IS A MEDIATOR OF ENDOTHELIAL CELL ACTIVATION IN SYSTEMIC SCLEROSIS

Background

In one of our previous studies, we demonstrated that long non-coding RNA (lncRNA) H19X plays a crucial role in the development of TGFβ driven fibrosis in systemic sclerosis (SSc) and other fibrotic diseases1.

Objectives

To define the functional relevance of H19X in endothelial cell (EC) activation as a decisive process in SSc vasculopathy.

Methods

Correlation of H19X expression and microvascular gene signature was computed on bulk RNA-Seq data derived from SSc skin biopsies of patients enrolled in the multicentre Prospective Registry of Early Systemic Sclerosis cohort (PRESS, n=48 SSc vs. n=33 healthy controls, HCs). Single cell RNA sequencing (scRNA-seq) data were collected from 27 diffuse cutaneous SSc (dcSSc) and 10 HC skin biopsies. Single cells were barcoded and encapsulated in droplets using a 10X Genomics system. After cDNA synthesis, the libraries were prepared and sequenced using Illumina NovaSeq-500 platform. Seurat package in R (v.3.0) was used to perform data analysis. EC were identified by enrichment of EC markers CLDN5, VWF and PECAM1. One thousand five hundred eighty-three and 3398 EC were identified from HC and SSc patients, respectively. Cells were analysed for the expression of H19X and EC activation markers. Additionally, differential expression and pathway enrichment analysis between H19X expressing cells and H19X negative cells was carried out. The function of H19X was investigated in human dermal microvascular EC (HDMEC) by silencing, using locked nucleic acid antisense oligonucleotides (LNA GapmeRs). Gene expression was measured by qPCR. Protein levels of endothelial adhesion molecules were analysed by Western Blot. Endothelial adhesion was evaluated by co-culture of HDMEC and fluorescently labelled peripheral blood mononuclear cells (PBMCs).

Results

H19X expression was found significantly upregulated in SSc skin biopsies of the PRESS cohort (p<0.0001). The expression of H19X positively correlated with the microvascular endothelial cell gene signature in all subjects (SSc and HC, R=0.43, p<0.0001), confirming that H19X is expressed in this cell type. To determine if H19X might be an important factor in SSc EC dysfunction scRNAseq was performed. This analysis revealed a significant upregulation of H19X in SSc EC as compared to HC EC (p=0.0095). H19X was found to be upregulated in several EC subclusters including arterial (SEMA3G, HEY1), capillary (CA4, RGCC), venous (ACKR1, VCAM1) and lymphatic (PROX1, LYVE1). H19X displayed highest expression in injured SSc EC and capillary SSc EC. Co-expression analysis of the scRNA-seq data revealed higher expression of several adhesion molecules in EC expressing H19X, including VCAM1, ICAM and JAM3. KEGG pathway analysis revealed that differentially expressed genes in H19X expressing cells were highly associated with the ‘Cell adhesion molecule’ pathway (p=2.209e-7). H19X silencing lead to a significant downregulation of mRNA levels of genes encoding adhesion molecules VCAM1 (n=7, p<0.05) and E-selectin (n=7, p<0.01) at 48h after transfection. VCAM1, but not E-Selectin, was also reduced at protein level as revealed by Western Blot (n=3). The functional relevance of H19X on endothelial adhesion was confirmed by PBMCs with H19X silenced HDMEC where we were able to demonstrate a significant decrease in leucocyte-to-endothelial cell adhesion (n=5, p<0.05).

Conclusion

Our results show that lncRNA H19X could contribute to EC activation in SSc vasculopathy, acting as a regulator of expression of adhesion molecules in EC.

References

[1]Pachera E, et al. Long noncoding RNA H19X is a key mediator of TGF-β-driven fibrosis. J Clin Invest. 2020 Sep 1;130(9):4888-4905.

Disclosure of Interests

Francesca Tirelli: None declared, Elena Pachera: None declared, Robert Lafyatis Consultant of: Pfizer, Bristol Myers Squibb, Boehringer-Ingleheim, Formation, Sanofi, Boehringer-Mannheim, Merck and Genentech/Roche, Grant/research support from: Corbus, Formation, Moderna, Regeneron, Pfizer and Kiniksa, Menqi Huang: None declared, Shervin Assassi: None declared, Eva Camarillo: None declared, Francesco Zulian: None declared, Gabriela Kania: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim.

POS0873 PERSISTENT INFLAMMATION IN SYSTEMIC SCLEROSIS IS STRONGLY ASSOCIATED WITH SEVERE DISEASE AND MORTALITY: AN ANALYSIS FROM THE EUSTAR DATABASE

Background

Systemic sclerosis (SSc) is a heterogeneous autoimmune disease, with a high disease-related mortality and morbidity. A subset of patients show elevated CRP levels (20-35%), which has been reported as inflammatory SSc. Preliminary data suggest that this subset is characterized by a severe phenotype.

Objectives

To analyse the phenotype and the survival of inflammatory compared with non-inflammatory SSc patient subsets.

Methods

Data from 8571 SSc patients with available CRP measurement from the EUSTAR cohort were analysed. Exclusion criteria included acute infection, missing follow-up and tocilizumab treatment. Patients with a CRP ≥5mg/l at ≥80% of visits were stratified as persistent inflammatory and as non-inflammatory if CRP was ≥5 mg/l at <20% of visits (as described previously (1)). As a sensitivity analysis, patients were defined as inflammatory and non-inflammatory based on a single CRP measurement at baseline only (CRP ≥5 or <5mg/l, respectively). We compared baseline characteristics using Chi-square and non-parametric Kruskal–Wallis tests as appropriate. Kaplan Meier curves with log-rank tests were used to estimate time from baseline to death or censoring, and Cox regression to compare mortality risks adjusted for time from diagnosis to baseline.

Results

Out of 2883 patients with more than two visits, 404 (14%) showed persistent inflammation and 1032 (36%) a non-inflammatory phenotype. Out of 5619 patients with more than one visit, 1830 (33%) were stratified as inflammatory as defined by as single CRP measurement at baseline and 3789 (67%) as non-inflammatory. With both definitions, the inflammatory subset revealed a more severe phenotype than non-inflammatory patients, including more frequent diffuse-cutaneous disease, anti-Scl-70 autoantibodies, pulmonary fibrosis, pulmonary hypertension, higher modified Rodnan skin score, and lower forced vital capacity and diffusing capacity for carbon monoxide. Patients with persistent inflammation had a strongly increased risk of all-cause mortality (HR 7.1 [95%CI 3.7 to 13.5], p<0.001) compared to non-inflammatory patients, whereas this association was weaker when based on a single CRP measurement (HR 2.6 [95%CI 2.1 to 3.2], p<0.001).

Conclusion

The severe phenotype and decreased survival of the inflammatory SSc subset, which was most prominent in patients with persistently elevated CRP levels, suggest a distinct disease subset. Therefore both, the need for more regular monitoring of inflammatory parameters and implications for immune-modulating treatment, needs to be carefully analysed.

References

[1]Mitev, A., et al., Inflammatory stays inflammatory: a subgroup of systemic sclerosis characterized by high morbidity and inflammatory resistance to cyclophosphamide. Arthritis Res Ther, 2019. 21(1): p. 262. PMID: 31791379

Figure 1.

Overall mortality from baseline onward a. by persistent inflammatory phenotype, b. by inflammatory phenotype at baseline

Disclosure of Interests

Adela-Cristina Sarbu: None declared, Sabina Guler: None declared, Odile Stadler: None declared, Yannick Allanore: None declared, Vera Bernardino: None declared, Jörg H.W. Distler: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Marco Matucci-Cerinic: None declared, Ulf Müller-Ladner: None declared, Vera Ortiz-Santamaria: None declared, Simona Rednic: None declared, Valeria Riccieri: None declared, Vanessa Smith: None declared, Susanne Ullman: None declared, Ulrich Walker: None declared, Thomas Geiser: None declared, Oliver Distler: None declared, Britta Maurer Speakers bureau: Boehringer-Ingelheim, Consultant of: Novartis, Boehringer Ingelheim, Janssen-Cilag, Grant/research support from: AbbVie, Protagen, Novartis Biomedical Research, Florian Kollert Shareholder of: Roche, Consultant of: BMS, Actelion, Boehringer-Ingelheim, Pfizer, Grant/research support from: Roche, Gilead, Pfizer, Employee of: Roche

AB0015 HOMEOBOX D13 TRANSCRIPTION FACTOR MODULATES THE FORMATION OF THE PRIMARY CILIUM IN RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLASTS

Background

Differences in gene expression and functions of synovial fibroblasts between distinct joints might lead to site-specific activation of arthritis-relevant pathways. We previously showed that the transcription factors HOX-D10, -D11 and -D13 are higher expressed in synovial fibroblasts from hands and feet compared to shoulder and knee, and that this expression pattern is epigenetically imprinted1.

Objectives

To investigate the functional role of HOXD13 in synovial fibroblasts.

Methods

Synovial fibroblasts from patients with rheumatoid arthritis (n=2) were cultured and transfected with HOXD13 antisense LNA GapmeRs (12.5 nM). Transcriptomes were determined by RNA-seq (Illumina NovaSeq 6000). Pathway enrichment analysis of RNA-seq data was performed using web-based tools (ToppGene, EnrichR and Cytoscape) (± fold change > 1.5, FDR < 0.05). The expression of histone deacetylases (HDACs) and sirtuins was measured by quantitative real-time PCR and immunofluorescence staining. Ciliogenesis of synovial fibroblasts was assessed by measuring the expression of PKD2, ARL13B, KIF3A, and IFT88 using qPCR. Acetylation of alpha-tubulin was assessed by immunofluorescence staining. Imaging was performed with the CellInsight™ CX7 platform. Primary cilia were manually counted. Approximately 500 cells for each replicate were recorded for the presence of a primary cilium. The length of primary cilia was measured using Image J (Version 1.53o). Synovial fibroblasts were treated with Trichostatin A (2µM), an inhibitor of HDACs (HDACi), for 24h.

Results

Pathway enrichment analysis of genes changed after HOXD13 silencing of synovial fibroblasts showed that HOXD13 regulated genes are involved in primary cilia related pathways. We confirmed lower mRNA expression of the ciliary proteins, PKD2, KIF3A and IFT88 after HOXD13 silencing (n=4; PKD2: 0.65 ± 0.4, p<0.05; KIF3a: 0.6 fold ± 0.3, p<0.05; IFT88: 0.7 fold ± 0.3, p<0.05), and higher expression of ARL13B (ARL13B: 1.8 fold ± 0.4, p<0.05). An increase in the number and length of primary cilia, as well as acetylation of alpha- tubulin, a characteristic feature of primary cilia, was seen after HOXD13 silencing (n=4). Accordingly, expression of HDAC4, -5 and -7 was decreased after HOXD13 silencing (n=4; HDAC4: 0.25 fold ± 0.1, p<0.05; HDAC5: 0.4 fold ± 0.1, p<0.05; HDAC7: 0.3 fold ± 0.2, p<0.05). SIRT1 expression was higher (n=4; 1.7 fold ± 0.4, p<0.05), but SIRT2 expression was lower (n=4; 0.1 fold ± 0.03, p<0.05) in HOXD13 silenced synovial fibroblasts. Trichostatin A treatment increased the acetylation level of alpha tubulin (n=4) as well as the expression of ARL13B, KIF3A, and IFT88 in synovial fibroblasts (n=4; ARL13B: 2.3 fold ± 0.9, p<0.05; IFT88: 1.5 fold ± 0.3, p<0.05; KIF3A: 3.7 fold± 1.8, p<0.05). The length and number of primary cilia was not changed by Trichostatin A treatment.

Conclusion

Our data show that HOXD13 plays a role in regulating the assembly of primary cilia in synovial fibroblasts. This effect seems partly mediated by the expression of HDACs and partly by the expression of ciliary proteins. The primary cilium is a sensory organelle mediating reactions to mechanical and chemical signals from the environment. Thus, our results suggest joint specific regulation of synovial fibroblasts in response to stimulation via the primary cilium.

References

[1]Klein K, et al. Ann Rheum Dis 2018;77: P126

Disclosure of Interests

Masoumehalsadat Mirrahimi: None declared, Eva Camarillo: None declared, Kerstin Klein: None declared, Miranda Houtman: None declared, Oliver Distler Consultant of: Abbvie, Caroline Ospelt: None declared

POS0205 SAFETY AND TOLERABILITY OF NINTEDANIB IN PATIENTS WITH AUTOIMMUNE DISEASE-RELATED INTERSTITIAL LUNG DISEASES (ILDs) IN SUBGROUPS BY SEX AND AGE

Background

Nintedanib slows the progression of fibrosing ILDs, with a safety profile characterised predominantly by gastrointestinal events.

Objectives

Assess the safety and tolerability of nintedanib in patients with autoimmune disease-related ILDs by sex and age.

Methods

The SENSCIS trial was conducted in patients with ILD associated with systemic sclerosis. The INBUILD trial was conducted in patients with progressive fibrosing ILDs other than idiopathic pulmonary fibrosis. Patients were randomised to receive nintedanib 150 mg bid or placebo. Dose reductions to 100 mg bid and treatment interruptions were permitted to manage adverse events (AEs). Data from all patients in SENSCIS and patients with autoimmune disease-related ILDs in INBUILD were pooled. In subgroups based on sex and age (<65 and ≥65 years) at baseline, we analysed AEs, irrespective of causality, over 52 weeks.

Results

Among 746 patients; 70.1% were female; 29.1% were aged ≥65 years. Mean (SD) exposure to nintedanib or placebo was 10.8 (3.2) and 11.1 (2.9) months in females and males, and 11.0 (3.0) and 10.6 (3.5) months in patients aged <65 and ≥65 years, respectively. The AE profile of nintedanib was similar between males and females, but nausea, vomiting, hepatic adverse events and dose reductions were more frequent in females. The AE profile of nintedanib was similar between patients aged <65 and ≥65 years, but nausea, decreased appetite, and weight loss were more frequent in patients aged ≥65 years. AEs leading to treatment discontinuation were more frequent in patients aged ≥65 years in both treatment groups. Serious AEs were more frequent in males and in patients aged ≥65 years in both treatment groups.

Conclusion

In patients with autoimmune-disease related ILDs, the AE profile of nintedanib in subgroups by sex and age was generally consistent with the known safety profile, but certain types of AE and dose reductions were more frequent in female patients, while serious AEs were more common in male patients.

Table 1.

Adverse events in patients with autoimmune disease-related ILDs in the SENSCIS and INBUILD trials in subgroups by sex and age at baseline.

FemaleMaleAge <65 yearsAge ≥65 yearsNintedanib(n=268)Placebo(n=255)Nintedanib(n=102)Placebo(n=121)Nintedanib(n=267)Placebo(n=262)Nintedanib(n=103)Placebo(n=114)Most frequent adverse events*Diarrhoea198 (73.9)77 (30.2)73 (71.6)38 (31.4)197 (73.8)85 (32.4)74 (71.8)30 (26.3)Nausea92 (34.3)35 (13.7)21 (20.6)14 (11.6)86 (32.2)38 (14.5)27 (26.2)11 (9.6)Vomiting73 (27.2)22 (8.6)12 (11.8)14 (11.6)61 (22.8)27 (10.3)24 (23.3)9 (7.9)Skin ulcer42 (15.7)37 (14.5)12 (11.8)13 (10.7)42 (15.7)45 (17.2)12 (11.7)5 (4.4)Nasopharyngitis34 (12.7)41 (16.1)12 (11.8)21 (17.4)33 (12.4)43 (16.4)13 (12.6)19 (16.7)Weight decreased34 (12.7)8 (3.1)10 (9.8)6 (5.0)29 (10.9)9 (3.4)15 (14.6)5 (4.4)Decreased appetite29 (10.8)9 (3.5)13 (12.7)4 (3.3)25 (9.4)10 (3.8)17 (16.5)3 (2.6)Abdominal pain32 (11.9)18 (7.1)8 (7.8)5 (4.1)27 (10.1)19 (7.3)13 (12.6)4 (3.5)Upper respiratory tract infection30 (11.2)31 (12.2)9 (8.8)8 (6.6)31 (11.6)33 (12.6)8 (7.8)6 (5.3)Cough23 (8.6)39 (15.3)13 (12.7)19 (15.7)27 (10.1)46 (17.6)9 (8.7)12 (10.5)Liver-related investigations, signs and symptoms49 (18.3)11 (4.3)13 (12.7)6 (5.0)42 (15.7)12 (4.6)20 (19.4)5 (4.4)Adverse event(s) leading to dose reduction101 (37.7)9 (3.5)18 (17.6)3 (2.5)81 (30.3)9 (3.4)38 (36.9)3 (2.6)Adverse event(s) leading to treatment discontinuation44 (16.4)21 (8.2)17 (16.7)13 (10.7)39 (14.6)18 (6.9)22 (21.4)16 (14.0)Serious adverse event(s)57 (21.3)53 (20.8)40 (39.2)37 (30.6)63 (23.6)54 (20.6)34 (33.0)36 (31.6)

n (%) of patients with ≥1 such adverse event over 52 weeks. Adverse events were coded based on preferred terms in the Medical Dictionary for Regulatory Activities (MedDRA), except for liver-related investigations, signs and symptoms, which was based on a standardised MedDRA query. *Adverse events reported in >10% of patients with autoimmune disease-related ILDs in the nintedanib or placebo group.

Acknowledgements

The SENSCIS and INBUILD trials were funded by Boehringer Ingelheim. Oliver Distler was a member of the SENSCIS trial Steering Committee.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Paid instructor for: Boehringer Ingelheim, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Elizabeth Volkmann Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, Corbus, Forbius, Horizon, Kadmon, Yannick Allanore Consultant of: Abbvie, Astra-Zeneca, Bayer, Boehringer, Mylan, Janssen, Medsenic, Prometheus, Roche, Sanofi, Grant/research support from: Alpine Immunosciences, Medsenic, OSE immunotherapeutics, Shervin Assassi Speakers bureau: On speaker bureau for Integrity Continuing Education, Consultant of: Abbvie, AstraZeneca, Boehringer Ingelheim, CSL Behring, Novartis, Grant/research support from: Boehringer Ingelheim, Janssen, Jeska de Vries-Bouwstra Speakers bureau: Boehringer Ingelheim, Janssen, Consultant of: Abbvie, Boehringer Ingelheim, Grant/research support from: Galapagos NV, Janssen and Roche B.V., Vanessa Smith Speakers bureau: Actelion Pharmaceuticals, Boehringer-Ingelheim Pharma GmbH&Co, Janssen-Cilag NV, UCB Biopharma Sprl

, Consultant of: Boehringer-Ingelheim Pharma GmbH&Co, Janssen-Cilag NV

, Grant/research support from: Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer-Ingelheim Pharma GmbH&Co, Janssen-Cilag NV, Research Foundation - Flanders (FWO)

, Inga Tschoepe Employee of: Inga Tschoepe is an employee of Elderbrook Solutions that is contracted by Boehringer Ingelheim., Lazaro Loaiza Employee of: Lazaro Loaiza is an employee of Boehringer Ingelheim, Madhu Kanakapura Employee of: Madhu Kanakapura is an employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

OP0102 THE SYNOVIUM IN CHRONIC INFLAMMATORY JOINT DISEASES: COMPARISON OF CLINICAL, HISTOLOGICAL AND scRNA-SEQ Data BETWEEN RA, PsA, SpA AND UA

Background

The synovium is the primary location of inflammation in various rheumatic diseases. However, specific differences of joint inflammation have not been explored on a single-cell level so far.

Objectives

To characterize the synovium of rheumatoid arthritis (RA), psoriatic arthritis (PsA), spondyloarthritis (SpA) and undifferentiated arthritis (UA) based on clinical and histological characteristics and single-cell RNA sequencing (scRNA-seq).

Methods

We performed ultrasound (US) guided synovial biopsy in patients fulfilling classification criteria: 10 RA, 4 PsA, 4 SpA and 3 UA. 3 osteoarthritis (OA) samples were obtained from surgery. Clinical data were collected at time of biopsy. Histological analysis of the synovium included Krenn score [1], synovial pathotype [2], vascularization [3] and presence of lymphoid follicles. OA histology was not available. We prepared scRNA-seq libraries with 10X Genomics and sequenced on NovaSeq 6000. ScRNA-seq data was analysed with Cell Ranger, Seurat and Harmony R packages. We selected overexpressed genes using log2 ratio (>0.25) and FDR adjusted p value < 0.05.

Results

Patients showed typical disease characteristics. In RA, 6/10 were seropositive, 8/10 were female and median age was 59 years (IQR 12). Patients with PsA, SpA and UA were seronegative. 2/4 SpA and 1/4 PsA patients were HLA-B27 positive. Median age was 53 years in PsA (IQR 14.2), 52.5 in SpA (IQR 14.8) and 53 in UA (IQR 3.5). In PsA 3/4, SpA 2/4 and UA 1/3 patients were male.

RA joints had significantly higher B-Mode US scores compared to PsA and SpA joints (mean B-Mode Score: RA 2.7; PsA 2; SpA 2). Correspondingly, RA patients reported a significantly higher amount of swelling in the biopsied joint compared to PsA and SpA (mean “Swelling-Score”: RA 6.85; PsA 4.25; SpA 4).

Histology showed no clear differences in the cell composition; most joints showed a lympho-myeloid pathotype. Mean Krenn Score was highest in RA (4.78) and lowest in SpA (3.33). PD-Mode US score showed a significant positive association with histological vascularization. Lymphoid follicles were significantly more seen in RA compared to all other diseases.

Integration of scRNA-seq data revealed 16 cell clusters with respective marker gene: PRG4 synovial fibroblasts (SF), THY1 SF, ACTA2 smooth muscle cells, VWF endothelial cells, TPSB2 mastcells, IGHG plasma cells, CD79 B-cells, CD69 T-Cells, CCL5 natural killer cells, DMTN Treg-cells, CXC2 neutrophil granulocytes, TREM2 macrophages, CD48 macrophages, CLEC10A macrophages, CD4 dendritic cells, MKI67 proliferating cells. OA had the lowest and RA the highest number of inflammatory cells within the synovium. SpA synovium had the highest number of neutrophils. Re-Clustering of only SF revealed 4 subtypes: PRG4 SF (3578 cells), CXCL12 SF (4539 cells), POSTN SF (2387 cells) and MFAP5 SF (1734 cells). Top 5 marker genes are shown in the Table 1. Most differentially expressed genes in OA were found in PRG4 SF; the previously described OA specific gene CSN1S1 [3] was not only underexpressed in RA but also in other inflammatory joint diseases (Figure 1). PGF, a gene associated with pathological angiogenesis, was one of the top discriminator genes, highly expressed in PsA SF (mostly PRG4 SF). RA SF (mostly CXCL12 SF) showed a high expression of CHI3L1, which is a RA specific autoantigen. High expression of hemoglobin genes was found in SpA PRG4 SF; an unexplored but previously described finding [5, 6].

Table 1.

Top 5 synovial fibroblast (SF) marker genes.

ClusterGenePRG4 SFPRG4CSN1S1MMP3CRTAC1HTRA1CXCL12 SFAPOECXCL12CCL2PTGDSCD74POSTN SFCOMPCOL1A1POSTNCILPPTNMFAP5 SFMFAP5SFRP2APODCXCL14CFD

Conclusion

We were able to compare the synovium of the most common chronic inflammatory joint diseases on various levels for the first time. The findings set the path for future diagnostic, prognostic, and therapeutic approaches in inflammatory joint diseases.

References

[1]Krenn et al, Histopath. 2006

[2]Humby et al, ARD 2019

[3]Kennedy et al, AR 2010

[4]Galligan et al, GI 2007

[5]Yeremenko et al, A&R 2012

[6]Park et al, JRD 2016

Disclosure of Interests

None declared

AB0135 PROTEIN CONFORMATIONAL CHANGES AND FUNCTIONAL ALTERATIONS IN DERMAL FIBROBLASTS FROM PATIENTS WITH SYSTEMIC SCLEROSIS

Background

Despite intensive studies and clinical trials, there is still no available precise diagnostic tool and treatment of the patients affected by systemic sclerosis (SSc). Proteopathies are diseases characterized by the production of aberrant conformers of certain proteins that lead to a disturbance of their cellular functions and disease. It is believed that the structure of a protein is principally responsible for its function. By identifying altered protein structures on a proteome-wide scale, there is a possibility to detect protein functional changes.

Objectives

To screen for changes in the protein conformation and to correlate with cell function in SSc dermal fibroblasts compared to fibroblasts from healthy donors (HC) using a novel approach of limited proteolysis followed by functional assays.

Methods

Diffuse cutaneous SSc and HC dermal fibroblasts were used for recently established Limited Proteolysis-coupled Mass-Spectrometry (Lip-MS)[1] to examine protein structural alterations in a proteome-wide scale. A change in conformation was defined as having a foldchange greater than 1 or smaller than -1 and a significant p-value of -log10 > 1.3 (≤0.05). Further, the responsive signalling targets in these cells, including the NF-κB-dependent pathway and energy metabolism, were evaluated. Fibroblasts were stimulated with inflammatory cytokines, highly relevant in SSc, including TNFα, IL-1β, TGF-β, IL-17A, and a combination of IL-17A and TGF-β. To examine the NF-κB activity, cells were transduced with a pseudo-typed HIV-1-based lentiviral vector. The measurements of luciferase signal were analysed. RT-qPCR was used to assess the expression of NF-κB-dependent genes for non-transduced cells. ATP measurements were analysed and presented as the amount of luminescent signal.

Results

LiP-MS analysis detected 53263 common peptides in SSc (n=6) and HC fibroblasts (n=6), of which 41 peptides showed conformational changes in SSc fibroblasts in comparison with HC fibroblasts. The 41 conformationally altered peptides showed significant enrichment in GO pathways for: biological processes (9), molecular function (7) and cellular components (21). SAE1, CTNND1, CDC37, and PPP1R13L were related to the NF-κB-dependent pathways, while ATP5A1, GSTM1, PCK2, ANPEP, GM2A, GNS, CAD, ACOT2 were connected with metabolic processes. There was a tendency of lower levels of mRNA RELA, NFKBIA, MMP1 and TNC expression levels in untreated and stimulated SSc fibroblasts (n=6) compared to HC fibroblasts (n=6). The assessment of the NF-κB activity in untreated SSc fibroblasts (n=9) showed a trend to lower fold change compared to HC fibroblasts (n=9) (0.63 vs 1, SE 0.19, p=0.07). A statistically significant difference between SSc (n=8) and HC (n=8) fibroblasts was found in TGF-β stimulated fibroblasts (0.64 vs 1, SE 0.16, p=0.046). SSc fibroblasts (n=9) showed a lower ATP level compared to HC fibroblasts (n=9) in untreated condition (0.82 vs 1, SE 0.09, p=0.07), after stimulation with IL-1β (0.85 vs 1, SE 0.08, p=0.07) and TGF-β (0.81 vs 1, SE 0.09, p=0.05). Of note, a statistically significant difference between SSc and HC fibroblasts was found in IL-17A stimulated cells (0.82 vs 1, SE 0.07, p=0.02).

Conclusion

LiP-MS approach allowed for the identification of conformational changes in SSc fibroblast mainly related to signal transduction and metabolic pathways. Confirmatory functional studies showed deregulated NF-κB activity and ATP levels in SSc fibroblasts. Therefore, LiP-MS approach may create a distinctive opportunity to discover new disease biomarkers and functionally transformed pathways. This method may advance therapeutical approaches, where only structurally altered proteins could be specifically targeted, without interfering with non-changed proteins.

References

[1]Schopper S, Kahraman A, Leuenberger P, Feng Y, Piazza I, Müller O, Boersema PJ, Picotti P. Measuring protein structural changes on a proteome-wide scale using limited proteolysis-coupled mass spectrometry. Nat Protoc. 2017 Nov;12(11):2391-2410.

Disclosure of Interests

None declared

POS0888 NON-SURGICAL LOCAL TREATMENTS FOR DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers(DUs) in systemic sclerosis(SSc) represent a major clinical challenge. There are no recommendations for the local management of SSc-DUs. Systemic therapy is considered the standard of care. However, there is a strong rationale for local approaches to DU by avoiding side effects from systemic therapies. The World Scleroderma Foundation DU Working Group intends to develop evidence-based recommendations for DU management including local, non-surgical treatment(ln-sT).

Objectives

To summarise the literature on the safety and efficacy of ln-sT for SSc-DUs.

Methods

A systematic literature review(SLR) of papers describing the use of ln-sT for DU in SSc was performed up to May 2021 according to the PICO framework. References were independently screened by two reviewers who independently assessed the full text of eligible articles and extracted data.

Results

Among 790 retrieved references, 12 were included. Median(range) number of patients per study was 9(7–84), mean age ranging from 37 to 62.5 years. In 5(41%) studies a control group was included. Background systemic therapies are summarized in Table 1. The most studied treatment was botulin toxin A(BTA). It was used as hand injection in 3 studies (median dose ranging from 90 to 150 U) and as 50 U single finger injection in 1 study. Healing rate after a median time of 8-49 weeks ranged from 71% to 100%. In 2 studies a reduction in VAS pain was observed from 20% to 100%. Transient muscle weakness was the most common side effect in 10% of patients. Amniotic(Am) and hydrocolloid membranes(HyM) were used in 1 study each. They were associated with a good healing rate, statistically significant for the HyM. Tadalafil 2% cream was studied in 1 study and was associated with a reduction in the median DU number from 1.6 to 1 per patient after a median time of 4 weeks and a reduction by 1.4 point in the 10-mm VAS scale. Vitamin E gel was shown to be associated with a statistically significant reduction in the healing time compared to SoC alone in 1 RCT(13.2 ± 2.7 versus 20.9 ± 3.6 weeks, P=<0.001). Low-level light therapy, hydrodissection and corticosteroid injection and extracorporeal shock wave(ESW) were evaluated in 1 study each. They were all associated with positive outcomes which was statistically significant only for the ESW. The only negative trial examined dimethyl sulfoxide and was associated with local toxicity.

Table 1.

Characteristics of the studies.

TreatmentType of studyPatientsBaseline DUBackground therapy (%) ETA CCB APA PG ARB ACE-I PDE-5i ISFollow-up (weeks)Healing rate(%)*Pain Reduction (VAS/10)ComparatorHydrodissection and corticosteroid injectionP1202334.4Rheumatoid ArthritisTadalafil 2% Vitamin E gelRRCT15131.6(1)3.5±2.30462700130704 241(1)Reduced time to heal**1.4SoCAmHyMRP67310001002800002817033143810090**SoCBTAMedian 90 U per handHigh-concentration hand100 U non-dominant handSingle finger 50 URRPP772010314571140718558551008514201001414718 4981277717510020%100%Untreated CHLow-level light therapyP8102537025378100ESWP9493355661144441**1.31Dimethyl sulfoxideDBRCT84No change, skin toxicity with 70% formulation

*Unless otherwise stated. **Statistically significant. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. APA= anti-platelet agents. CCB= calcium channel blockers. CH= contralateral hand. DBRCT= double blind randomized-controlled trial. ETA = endothelin antagonist. IS= immunosuppression. PG= prostaglandins. PDE-5i= Phosphodiesterase type-5 inhibitors. P = prospective. R = retrospective. SoC= standard of care (as per local protocol).

Conclusion

Our SLR supports interest to develop ln-sTs for SSc-DUs. The number of studies is limited and mainly case reports and small single studies are present. Treatments were well tolerated and there was evidence of efficacy for BTA, vitamin E, ESW and HyM in refractory DUs. The evidence is not robust and confounding factors (vasodilators background therapies) could impact on the findings. Future research is indicated to conduct larger, well-designed studies.

Disclosure of Interests

Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Michael Hughes Speakers bureau: Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work., Jan Schoones: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Nancy Maltez: None declared, Laura Ross: None declared, Murray Baron: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0388 DEVELOPING A SCREENING TOOL FOR THE DETECTION OF INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS: THE ILD-RISC RISK SCORE

Background

High resolution computed tomography (HRCT) is the gold standard for the diagnosis of systemic sclerosis associated interstitial lung disease (SSc-ILD). Although there is agreement in performing HRCT as a screening test at time of SSc diagnosis, some physicians do not regularly perform baseline HRCTs. In addition, it is unclear according to which criteria HRCTs should be repeated during the follow-up of baseline ILD negative patients.

Objectives

To develop a risk score for the presence of SSc-ILD (the ILD-RISC), to guide physicians in ordering both baseline and follow-up HRCTs.

Methods

The steering board included six SSc-ILD experts from referral centers, two fellows and a patient research partner. Items for regression analysis were selected according to face validity, feasibility, scientific background, and personal experience using the nominal group technique (NGT). The prediction model for the presence of ILD was developed from baseline visits of SSc patients from the six centers using multivariable logistic regression with backward selection. Patients were randomly divided into a derivation and validation cohort consisting of 66% and 34% of patients respectively. Patients with missing data in the selected covariates and in the ILD status (outcome) were excluded. After identifying a cut-off favoring sensitivity >85% from the ROC curve analysis, the derived ILD-RISC score was applied first in the validation cohort and then longitudinally in a cohort of SSc patients with negative baseline HRCT.

Results

The steering board selected 13 variables deemed important in the identification of SSc-ILD: sex, age, disease duration from first non-Raynaud’s phenomenon symptom, skin subset (diffuse/limited), presence of esophageal symptoms, digital ulcers (DU) ever, arthritis ever, smoking ever, increased inflammatory markers, NYHA functional class, SSc autoantibody status (SSc_Atb), FVC% and DLCO%. Among 780/3240 patients fulfilling the inclusion criteria, 533 (43% ILD) and 247 (48% ILD) respectively constituted the derivation and the validation cohort. In the derivation cohort, a model including FVC%, DLCO%, DU ever, age and SSc_Atb (Table 1A) showed an OR of 133.9 (95% CI 53.4-335.9) and an AUC of 79.1% (95% CI 75.3-83.0%) for the presence of ILD on HRCT (Figure 1). An ILD-RISC score ≥0.3 showed sensitivity of 85.6% and specificity of 53.6%, NPV of 83.2% and PPV of 58.2%, which were replicated in the validation cohort (Table 1B). Among 819 patients with negative baseline HRCT, 170 (20.8%) developed ILD during a 3.8±3.0 years follow up (1988 visits). Longitudinally, the ILD-RISC score showed comparable sensitivity and specificity (Table 1B).

Table 1.A)ILD-RISC MODEL VARIABLESOR95% CIp valueDigital ulcers, ever2.0581.347-3.145<0.001Age1.0261.010-1.0420.001SSc_ATBAnti-centromere0.3340.198-0.563<0.001Anti-topoisomerase I2.3791.326-4.2670.004Anti-RNA-polymerase III1.4070.636-3.1130.399Anti-Pm/Scl2.5560.916-7.1350.073None of the aboveComparatorFVC%0.9900.979-1.0020.091DLCO%0.9710.960-0.982<0.001B)ILD-RISC SCORE PERFORMANCEDerivation cohortValidation cohortLongitudinal cohortAll Patients/ILD patients533/229247/119819/170AUC %, 95% CI79.1 (75.3 – 83.0)76.4 (71.0 – 82.7)72.6 (68.9 – 76.2)Sensitivity %, 95% CI85.6 (80.4 – 89.9)85.7 (78.1 – 91.5)80.4 (73.9 – 86.0)Specificity %, 95% CI53.6 (47.8 – 59.3)49.2 (40.3 – 58.2)50.5 (48.2 – 52.9)Negative Predictive Value %, 95% CI83.2 (77.2 – 88.1)78.8 (68.2 – 87.1)96.3 (94.9 – 97.4)Positive Predictive Value %, 95% CI58.2 (52.7 – 63.5)61.1 (53.2 – 68.5)13.9 (11.8 – 16.1)

Conclusion

We developed and validated the ILD-RISC score to predict the presence of ILD at time of diagnosis and evaluated its performance during follow-up. The ILD-RISC may be useful in routine practice when resources for HRCTs might be limited. In particular, it may also help to decide when to order HRCTs at follow up, thus limiting unnecessary HRCTs and reducing the burden for patients and institutions.

Disclosure of Interests

Cosimo Bruni Speakers bureau: Actelion, Consultant of: Boehringer-Ingelheim, Eli-Lilly, Grant/research support from: New Horizon fellowship, FOREUM, EUSTAR, GILS, Lorenzo Tofani: None declared, Håvard Fretheim: None declared, Sophie Liem: None declared, Arthiha Velauthapillai: None declared, Hilde Jenssen Bjørkekjær: None declared, Imon Barua: None declared, Ilaria Galetti: None declared, Alexandru Garaiman: None declared, Mike O. Becker Speakers bureau: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Consultant of: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Grant/research support from: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Anna-Maria Hoffmann-Vold Consultant of: Actelion, ARXX therapeutics, Bayer, Janssen, MSD, Lilly, Roche, Boehringer-Ingelheim, Medscape., Jeska de Vries-Bouwstra Speakers bureau: Payment for presentations and educational events by Boehringer Ingelheim and Janssen, Consultant of: Janssen and Boehringer Ingelheim, Abbvie, Grant/research support from: Roche, Galapagos and Janssen, ZonMW and ReumaNederland, Madelon Vonk: None declared, Jörg H.W. Distler Shareholder of: J.H.W.D. is stock owner of 4D Science and Scientific head of FibroCure., Grant/research support from: J.H.W.D. has received research funding from Anamar, Active Biotech, Array Biopharma, aTyr, BMS, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, Novartis, Sanofi-Aventis, RedX, UCB., Marco Matucci-Cerinic Speakers bureau: Biogen, Bayer, Boehringer-Ingelheim, CSL Behring, Eli-Lilly., Consultant of: Actelion, Biogen, Bayer, Boehringer-Ingelheim, CSL Behring, Eli-Lilly., Grant/research support from: Actelion, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim

POS0898 SURGICAL MANAGEMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Management of digital ulcers (DUs) in systemic sclerosis (SSc) is a major clinical challenge. To date, systemic therapy is generally considered as the ‘standard of care’ for significant SSc-DUs. However, there is a strong rationale to develop local approaches to DUs, to avoid side effects from systemic therapies. World Scleroderma Foundation DU Working Group intends to develop practical, evidence-based recommendations for DU management including local, Surgical Treatment (L-ST).

Objectives

To summarize the literature on the safety and efficacy of L-ST for SSc-DUs.

Methods

A systematic literature review (SLR) was conducted up to May 2021. According to the PICO framework, eligibility criteria were defined and original research articles about surgical treatment of SSc DUs in adult patients were included. References were independently screened by 2 reviewers who assessed the full text of eligible articles and extracted data.

Results

Thirteen eligible articles out of 790 total publications were identified (Table 1). Due to the paucity of randomized controlled trials of surgical treatments for SSc-DU, we included retrospective studies and case series with at least 4 patients. Autologous fat (adipose tissue AT) grafting was the surgical modality mostly identified (7 studies of which 1 RCT and 6 prospective open label single arm). The healing rate (HR) with autologous fat grafting (4 studies) ranged from 66-100 %. In the RCT, two age and sex matched groups were included, adipose tissue (AT)group (n=25 pts) and sham procedure (SP) group (n=13), DU healing was reported in 23/25 in AT group versus 1/13 in the SP group in 8 wks, (p<0.0001), 12 pts in the SP group, received rescue AT injection, all of them healed after 8 wks. Three studies reported autologous adipose-derived stromal vascular fraction(SVF) grafting and the HR ranged from 32-60%, followed up to 12 months. Transient edema and paresthesia were reported in 2 studies, and amputation in 2 ulcers in 1 study, and no complications were reported in other studies. Surgical sympathectomy was reported in 3 studies, with a median healing rate of 81%. Bone marrow derived cell transplantation in a single study showed 87% healing rate over (4-24 wks). Two surgical studies (of direct microsurgical revascularization N=4, and microsurgical arteriolysis, N=6), showed 100% healing of ulcers, no complications reported.

Table 1.

Characteristics of the extracted studies.

StudydesignPatients (n)Baseline DU (n)Background therapy (%)Follow-upOutcomeHealed ulcers(%) Adipose tissue graftAutologous fat graftp9.15PG, CCB—100ETA 26PDE-5i 138-12 wks66Adipose tissue graftingRCT25 case13- Ctr25-case13- CtrPG- 100CCB 1008 wks92-case7-CtrAdipose tissue implantp1515no therapy7 wks100Adipose tissue graftp129PG,CCB-100ETA6 month88adipose derived SVFp1215PDE-5i, ccb, PG allowed22m6Adipose derived SVFp1215CCB 50ETA166 m63 Adipose derived SVFp1819CCB 50PG 27ETA 5IS 7124 wks32SympathectomySympathectomyR611CCB-10020 m81SympathectomyR1335PGCCBAPA35Sympathectomy, vascular bypass (+vein graftR1726Ccb 35APA 47PDE-i5 589 m100Bone marrow derived cells transplantation)p88PG-6236 m87Direct microsurgical revascularizationR44m100Limited microsurgical arteriolysisR61712 m100

SVF =stromal vascular fraction P = prospective. R = retrospective. RCT= double blind randomized-controlled trial. ETA = endothelin antagonist. CCB= calcium channel blockers. APA= anti-platelet agents. PG= prostaglandins. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. PDE-5i= PDE-5 inhibitors. IS= immunosuppression. M=median. SoC= standard of care. HR= healing rate

Conclusion

Our SLR has identified several surgical modalities for SSc-DUs. L-STseemed generally effective and safe for DU healing, thus Significant methodological issues emerged including small numbers of pts, lack of comparator, failure to report confounders such as background therapies and variable follow up. Future research is warranted to rigorously investigate surgical interventions for Dus.

Disclosure of Interests

Yossra A. Suliman: None declared, Corrado Campochiaro: None declared, Michael Hughes Speakers bureau: speaking fees from Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work, Jan Schoones: None declared, Dilia Giuggioli: None declared, Nancy Maltez: None declared, Pia Moinzadeh Speakers bureau:: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Laura Ross: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Murray Baron: None declared, Christopher P Denton: None declared, Oliver Distler Shareholder of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Speakers bureau: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Paid instructor for: Janssen and Eicos Sciences, Inc., Consultant of: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka KUWANA Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Paid instructor for: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Consultant of: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0479 STAT3 DEGRADERS PROTECT FROM IMMUNOFIBROTIC CHANGES IN PRECLINICAL MODELS

Background

The ubiquitin-proteasome system (UPS) is the endogenous intracellular mechanism for maintaining protein homeostasis through protein degradation and turnover. Heterobifunctional small molecules are a new class of compounds that form a ternary complex with an E3 ligase and protein of interest leading to ubiquitination and subsequent degradation of the protein of interest in a process known as Targeted Protein Degradation. This new therapeutic modality enables targeting of “undruggable” proteins such as STAT3, a transcription factor activated in immunofibrotic diseases.

Objectives

Kymera has developed heterobifunctional molecules that potently and selectively target STAT3 for degradation and elimination by the ubiquitin-proteasome pathway. The aim of these studies was to evaluate the therapeutic potential of pharmacologically removing STAT3 by targeted protein degradation in various human cell types in vitro, and to prevent the development of skin and lung fibrosis in vivo.

Methods

Dermal fibroblasts obtained from healthy and systemic sclerosis patients activated with TGF-β were analyzed for development of α-smooth muscle actin (α-SMA)-positive stress fibers and for contractility using collagen gel contraction assay. Contraction assay was also performed using human dermal smooth muscle cells. Human aortic endothelial cells (HAECs) were activated with LPS, and their adhesive properties were assessed in the microcapillary system by the ability to bind peripheral blood mononuclear cells (PBMCs) under shear stress. HAECs proliferation was induced with VEGF. THP-1 cells and CD14+ monocytes were activated with IL-6 or LPS, and secreted cytokines were assessed by CBA. PBMCs activated with LPS, IL-6, IL-21, or IL-23 alone (pSTAT3 induction), or with a combination of anti-CD3/CD38 beads and a pro-Th17 cocktail comprised of cytokines and antibodies to evaluate the development of a Th17 and Treg phenotype by flow cytometry. Cytokines were analyzed by ELISA. All cell types were pre-treated with STAT3 degraders 20h prior to experiment start. Intratracheal instillation of bleomycin was used to induce pulmonary fibrosis. Transgenic Tsk-1 mice were used as a model of spontaneous skin fibrosis.

Results

STAT3 degraders completely ablated STAT3 in all analyzed cell types with DC50 ranging from 0.25-0.8 nM. STAT3 degradation prevented TGF-β-induced formation of α-SMA-positive stress fibers in dermal fibroblasts (IC50 = 0.35nM) and 2 and 10nM degrader completely abrogated their contractility. Similarly, STAT3 degradation reduced the constitutive contractility of dermal smooth muscle cells of 13% (p<0.05, n=6). Treatment of HAECs with STAT3 degraders resulted in anti-adhesive 178±21 for LPS and 93±12 for LPS +degrader, p<0.05, n=6) and anti-proliferative 1.2±0.1 for VEGF and 0.95±0.1 for VEGF +degrader, p<0.05, n=10-11) effects. In monocyte-focused assays (CD14+ monocytes and THP-1 cells), STAT3 degradation potently and dose-dependently inhibited IL-6 and LPS-induced pSTAT3 levels and the ensuing release of MCP-1/CCL2 (24.3±3.7 for LPS and 20.2±3.2 for LPS +degrader, p<0.05, n=6). In CD4+ T lymphocytes, STAT3 degradation promoted a Treg phenotype and suppressed the development of Th17 cells. Systemic treatment in vivo showed that prophylactic STAT3 degradation (7 mg/kg twice a week, i.p.) reduced disease severity in the bleomycin-induced pulmonary fibrosis model (Ashcroft‘s score, 4.7±1.9 vs. 3.1±1.6, p<0.05, n=11). In Tsk-1 mice that show co-occurrence of spontaneous skin thickening and robust STAT3 activation, STAT3 degrader treatment (2 or 7 mg/kg twice a week, i.p.) for 7 weeks significantly reduced thickness of the skin (701±238 vs. 480±205 vs. 365±107, p<0.05, n=6-8).

Conclusion

STAT3 degraders that selectively and potently eliminate STAT3 show robust anti-inflammatory and anti-fibrotic potential in vitro and in vivo. Our results suggest that targeted protein degradation is a promising approach to modulate the STAT3 pathway, making it a novel therapeutic opportunity to treating multiple immunofibrotic diseases.

Disclosure of Interests

Przemyslaw Blyszczuk Grant/research support from: Kymera, Gabriela Kania: None declared, Elena Pachera: None declared, Filip Rolski: None declared, Amela Hukara: None declared, Vanessa Tela: None declared, Michele Mayo Employee of: Kymera, Vaishali Dixit Employee of: Kymera, Bin Yang Employee of: Kymera, Jared Gollob Employee of: Kymera, Nello Mainolfi Employee of: Kymera, Anthony Slavin Employee of: Kymera, Cedric Hubeau Employee of: Kymera, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim.

POS0893 FACTORS TO CONSIDER FOR MEASURING THE EFFECT OF LUNG FUNCTION ON PATIENT REPORTED OUTCOMES IN SYSTEMIC SCLEROSIS PATIENTS: ANALYSIS OF THE EUSTAR DATABASE

Background

Patient Reported Outcomes (PROs) are central to measure how patients feel and function especially when determining the effect of disease modifying agents. In patients with Systemic Sclerosis associated Interstitial Lung Disease (SSc-ILD), dyspnea is the main driver of HAQ decline but the effect of reduced lung function on both generic and specific measures of functional impairment is not well defined, and there are many potential confounding biases that could distort the apparent extent and direction of this relationship. Moreover, collider biases potentially induced by selection into the cohort and in clinical trials can also play a role.

Objectives

To define within the EUSTAR database, the correlation of Forced Vital Capacity (FVC) and functional impairment PROs and identify potential confounders to be considered in casual inference studies.

Methods

A cross-sectional analysis included for each patient with SSc-ILD (by X-ray and/or HRCT) in the EUSTAR registry the last visit with at least one PRO (Health Assessment Questionnaire Disability Index [HAQ-DI], Cochin hand function scale [CHFS] and/or dyspnoea visual analogue scale [VAS]) and % predicted FVC (%pFVC), if available. Patients with LVEF≤50% or pulmonary arterial hypertension at RHC were excluded. SSc-ILD with restricted lung volume was defined as %pFVC≤70 [1]. Spearman’s correlation analysis was performed. Results of this analysis and literature review were integrated to design a directed acyclic graph (DAG) and identify the appropriate confounder adjustment set for the total causal effect of FVC on functional impairment PROs.

Results

Among 17.338 SSc patients in the EUSTAR registry (extracted in November 2019), 727 SSc-ILD patients fulfilled the inclusion criteria (median %pFVC 90 (IQR 74-104), median %pDLCO 60 (IQR 47-52)). Patients with %pFVC<70 (n=149), as compared to those with %pFVC≥70 (n=578) had worse HAQ-DI, CHFS and VAS-dyspnoea scores (Table 1). In unadjusted analysis, %pFVC showed a weak correlation with HAQ-DI (r=-0.21) and CHFS (r=-0.17), but a stronger correlation with VAS dyspnoea (r=-0.33).

Table 1.

Results are reported as number/number available (%) for dichotomic variables, or as median (IQR) (n available) for continuous variables.

%pFVC≥70 (n=578)%pFVC<70 (n=149)Age at disease onset (years)60.6 (52.3-69.3) (546)52.5 (45.6-63-7) (137)Disease duration (months)134.4 (77.5-212.2) (546)110.3 (66.3-199.7) (137)Male sex84/578 (14.5)32/149 (21.5)Anti-Scl70+231/468 (40.7)81/122 (66.4)Smoker ever52/389 (13.4)17/107 (15.9)Caucasian ethnicity545/569 (95.8)131/145 (90.3)dcSSc167/559 (29.9)74/147 (50.3)Oesophageal symptoms319/571 (55.9)93/147 (63.3)Muscle weakness78/565 (13.8)37/149 (24.8)CRP elevation141/540 (26.1)53/134 (39.6)Elevated sPAP (ECHO)45/456 (9.9)21/121 (17.2)Pericardial effusion2/448 (0.4)4/110 (3.6)Diastolic function abnormality151/431 (35.0)31/102 (30.4)Conduction blocks78/480 (16.3)35/120 (29.2)%pDLCO62 (52-74) (527)42 (35-53) (118)CHFS7 (1-23) (493)16 (2-34.8) (114)HAQ-DI0.63 (0.13-1.13) (578)1.25 (0.38-2) (139)VAS dyspnoea (0-100)15 (10-45) (391)40 (20-70) (109)NYHA stage 3/447/561 (8.4)37/143 (25.9)

Subsequently, we created a DAG showing the proposed causal pathway considered relevant to the relationship between FVC and HAQ (Figure 1).

Conclusion

Lung function as measured by FVC appears to correlate with worse patient-reported function in our unadjusted analysis of the large multicentre EUSTAR dataset. However, to estimate the total causal effect we must consider a multitude of potentially confounding factors, which need to be integrated and analysed in a causal inference framework. The proposed DAG will inform the development of simulations of the potential impact of bias (confounding, collider and omitted variable) on effect estimates we could obtain from EUSTAR cohort.

References

[1]Goh NS, et al. Am J Respir Crit Care Med, 2008.

Disclosure of Interests

Maria Grazia Lazzaroni Grant/research support from: Research grant from Boehringer-Ingelheim, Michelle Wilson Grant/research support from: Research grant from Boehringer-Ingelheim, Elizabeth Hensor: None declared, Jörg H.W. Distler: None declared, Giovanna Cuomo: None declared, Elise Siegert: None declared, Ulf Müller-Ladner: None declared, Yannick Allanore: None declared, Maria Joao Salvador: None declared, Branimir Anic: None declared, Ulrich Walker: None declared, László Czirják: None declared, Camillo Ribi: None declared, Cristina-Mihaela Tanaseanu: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Oliver Distler: None declared, Francesco Del Galdo: None declared

POS0201 COVID-19 SEVERITY AND VACCINE BREAKTHROUGH INFECTIONS IN IDIOPATHIC INFLAMMATORY MYOPATHIES, OTHER SYSTEMIC AUTOIMMUNE AND INFLAMMATORY DISEASES, AND HEALTHY INDIVIDUALS: RESULTS FROM THE COVID-19 VACCINATION IN AUTOIMMUNE DISEASES (COVAD) STUDY

Background

Significant gaps are present in the evidence of the spectrum and severity of COVID-19 infection in idiopathic inflammatory myopathies (IIM). IIM patients typically require immunosuppressive therapy, may have multiple disease sequelae, and frequent comorbidities, and thus may be more susceptible to severe COVID-19 infection and complications (1). The possibility of attenuated immunogenicity and reduced efficacy of COVID-19 vaccines due to concomitant immunosuppressive medication is a major concern in these patients, and there is little data available on COVID-19 vaccine breakthrough infections (BI) in IIM (2).

Objectives

This study aimed to compare disease spectrum and severity and COVID-19 BI in patients with IIM, other systemic autoimmune and inflammatory diseases (SAIDs) and healthy controls (HCs).

Methods

We developed an extensive self-reporting electronic-survey (COVAD survey) featuring 36 questions to collect respondent demographics, SAID details, COVID-19 infection history, COVID-19 vaccination details, 7-day post vaccination adverse events and patient reported outcome measures using the PROMIS tool. After pilot testing, validation, translation into 18 languages on the online platform surveymonkey.com, and vetting by international experts, the COVAD survey was circulated in early 2021 by a multicenter study group of >110 collaborators in 94 countries. BI was defined as COVID-19 infection occurring more than 2 weeks after receiving 1st or 2nd dose of a COVID-19 vaccine. We analyzed data from the baseline survey for descriptive and intergroup comparative statistics based on data distribution and variable type.

Results

10900 respondents [mean age 42 (30-55) years, 74% females and 45% Caucasians] were analyzed. 1,227 (11.2%) had IIM, 4,640 (42.6%) had other SAIDs, and 5,033 (46.2%) were HC. All respondents included in the final analysis had received a single dose of the vaccine and 69% had received 2 primary doses. Pfizer (39.8%) was the most common vaccine received, followed by Oxford/AstraZeneca (13.4%), and Covishield (10.9%). IIM patients were older, had a higher Caucasian representation and higher Pfizer uptake than other SAIDs, and HC. A higher proportion of IIM patients received immunosuppressants than other SAIDs.

IIMs were at a lower risk of symptomatic pre-vaccination COVID-19 infection compared to SAIDs [multivariate OR 0.6 (0.4-0.8)] and HCs [multivariate OR 0.39 (0.28-0.54)], yet at a higher risk of hospitalization due to COVID-19 compared to SAIDs [univariate OR 2.3 (1.2-3.5)] and HCs [multivariate OR 2.5 (1.1-5.8)]. BIs were very uncommon in IIM patients, with only 17 (1.4%) reporting BI. IIM patients were at a higher risk of contracting COVID-19 prior to vaccination than ≤2 weeks of vaccination [univariate OR 8 (4.1-15)] or BI [univariate OR 4.6 (2.7-8.0)]. BIs were equally severe compared to when they occurred prior to vaccination in IIMs, and were comparable between IIM, SAIDs, and HC (Figure 1), though BI disease duration was shorter in IIMs than SAIDs (7 vs 11 days, p 0.027). 13/17 IIM patients with BI were on immunosuppressants.

Conclusion

IIM patients experienced COVID-19 infection less frequently prior to vaccination but were at a higher risk of hospitalization and requirement for oxygen therapy compared with patients with HC. Breakthrough COVID-19 infections were rare (1.4%) in vaccinated IIM patients, and were similar to HC and SAIDs, except for shorter disease duration in IIM.

References

[1]Brito-Zerón P, Sisó-Almirall A, Flores-Chavez A, Retamozo S, Ramos-Casals M. SARS-CoV-2 infection in patients with systemic autoimmune diseases. Clin Exp Rheumatol. 2021 Jun;39(3):676–87.

[2]Wack S, Patton T, Ferris LK. COVID-19 vaccine safety and efficacy in patients with immune-mediated inflammatory disease: Review of available evidence. J Am Acad Dermatol. 2021 Nov;85(5):1274–84.

Acknowledgements

The authors thank all members of the COVAD study group for their invaluable role in the collection of data. The authors thank all respondents for filling the questionnaire. The authors thank The Myositis Association, Myositis India, Myositis UK, the Myositis Global Network, Cure JM, Cure IBM, Sjögren’s India Foundation, EULAR PARE, and various other patient support groups and organizations for their invaluable contribution in the dissemination of this survey among patients which made the data collection possible. The authors also thank all members of the COVAD study group.

Disclosure of Interests

Latika Gupta: None declared, Leonardo Santos Hoff: None declared, Naveen R: None declared, Parikshit Sen: None declared, Samuel Katsuyuki Shinjo: None declared, Jessica Day Grant/research support from: JD has received research funding from CSL Limited, James B. Lilleker: None declared, Vishwesh Agarwal: None declared, Sinan Kardes: None declared, Minchul Kim: None declared, Ashima Makol: None declared, Marcin Milchert: None declared, Tamer A Gheita: None declared, Babur Salim: None declared, Tsvetelina Velikova: None declared, Abraham Edgar Gracia-Ramos: None declared, Ioannis Parodis Speakers bureau: IP has received research funding and/or honoraria from Amgen, AstraZeneca, Aurinia Pharmaceuticals, Elli Lilly and Company, Gilead Sciences, GlaxoSmithKline, Janssen Pharmaceuticals, Novartis and F. Hoffmann-La Roche AG., Consultant of: IP has received research funding and/or honoraria from Amgen, AstraZeneca, Aurinia Pharmaceuticals, Elli Lilly and Company, Gilead Sciences, GlaxoSmithKline, Janssen Pharmaceuticals, Novartis and F. Hoffmann-La Roche AG., Grant/research support from: IP has received research funding and/or honoraria from Amgen, AstraZeneca, Aurinia Pharmaceuticals, Elli Lilly and Company, Gilead Sciences, GlaxoSmithKline, Janssen Pharmaceuticals, Novartis and F. Hoffmann-La Roche AG., Albert Selva-O’Callaghan: None declared, Elena Nikiphorou Speakers bureau: EN has received speaker honoraria/participated in advisory boards for Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Consultant of: EN has received speaker honoraria/participated in advisory boards for Celltrion, Pfizer, Sanofi, Gilead, Galapagos, AbbVie, Lilly, Grant/research support from: EN holds research grants from Pfizer and Lilly., Tulika Chatterjee: None declared, Ai Lyn Tan Speakers bureau: ALT has received honoraria for advisory boards and speaking for Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB., Consultant of: ALT has received honoraria for advisory boards and speaking for Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB., Arvind Nune: None declared, Lorenzo Cavagna: None declared, Miguel A Saavedra: None declared, Nelly Ziade Speakers bureau: NZ has received speaker fees, advisory board fees and research grants from Pfizer, Roche, Abbvie, Eli Lilly, NewBridge, Sanofi-Aventis, Boehringer Ingelheim, Janssen, Pierre Fabre; none is related to this manuscript, Consultant of: NZ has received speaker fees, advisory board fees and research grants from Pfizer, Roche, Abbvie, Eli Lilly, NewBridge, Sanofi-Aventis, Boehringer Ingelheim, Janssen, Pierre Fabre; none is related to this manuscript, Grant/research support from: NZ has received speaker fees, advisory board fees and research grants from Pfizer, Roche, Abbvie, Eli Lilly, NewBridge, Sanofi-Aventis, Boehringer Ingelheim, Janssen, Pierre Fabre; none is related to this manuscript, Johannes Knitza: None declared, Masataka Kuwana: None declared, Oliver Distler Speakers bureau: OD has/had consultancy relationship with and/or has received research funding from or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Mitsubishi Tanabe, Novartis, Roche, Roivant, Sanofi, Serodapharm, Topadur and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: OD has/had consultancy relationship with and/or has received research funding from or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Mitsubishi Tanabe, Novartis, Roche, Roivant, Sanofi, Serodapharm, Topadur and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: OD has/had consultancy relationship with and/or has received research funding from or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon (Curzion), Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Mitsubishi Tanabe, Novartis, Roche, Roivant, Sanofi, Serodapharm, Topadur and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Hector Chinoy Speakers bureau: HC has been a speaker for UCB, Biogen., Consultant of: HC has received consulting fees from Novartis, Eli Lilly, Orphazyme, Astra Zeneca, Grant/research support from: HC has received grant support from Eli Lilly and UCB, Vikas Agarwal: None declared, Rohit Aggarwal Consultant of: RA has/had a consultancy relationship with and/or has received research funding from the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, and Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant., Grant/research support from: RA has/had a consultancy relationship with and/or has received research funding from the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, and Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant.

POS0486 IDENTIFICATION OF NEW CANDIDATE TARGETS INVOLVED IN ACTIVATION OF CARDIAC FIBROBLASTS UNDER IMMUNOFIBROTIC CONDITIONS

Background

Inflammatory dilated cardiomyopathy (iDCM) often leads to heart failure (HF), which is the main cause of mortality in patients with systemic diseases. Fibroblast activation, driven by the activator protein 1 family member Fos-related antigen 2 (FOSL2), represents a critical step in cardiac fibrogenesis. The existing antifibrotic therapies, based on known fibrotic markers, failed to demonstrate efficacy against myocardial fibrosis.

Objectives

To identify new candidate targets implicated in cardiac fibrogenesis under immunofibrotic conditions.

Methods

Cardiac fibroblasts were isolated from the left atria of patients (n=5) undergoing heart transplantation due to HF associated with iDCM and from unaffected hearts of brain-dead donors (UDs, n=5). Protein identification and quantification was performed using liquid chromatography tandem-mass spectrometry (LC–MS/MS). The data were analysed with MaxQuant v1.6.2.3 software. Bulk RNA sequencing (RNA-seq) was conducted using the Illumina HiSeq platform. Differentially expressed genes were identified using DESeq2. Additionally, we analysed publicly available single-cell (sc) RNA sequencing datasets (GSE109816, GSE121893) [1] on adult hearts from HF patients (n=6) and UDs (n=14) using Seurat package (V.2.3.4). Specific gene knockdown was achieved by siRNA transfection of human foetal cardiac fibroblasts (HCFs, Sigma), untreated or stimulated with TGF-β for 48-72h. The profibrotic marker expression was assessed using RT-qPCR and Western Blot. Cell viability was measured using PrestoBlue HS reagent (Invitrogen), and ATP production was quantified with CellTiter-Glo assay (Promega) in untreated and TGF-β-stimulated HCFs 48h after transfection.

Results

The LC–MS/MS analysis revealed 14 differentially expressed proteins (absolute log2FC>1, adj. p<0.05) in the HF group compared to UDs. The most upregulated protein in HF fibroblasts was dysferlin (DYSF, log2FC=5.78, adj. p<0.004), which is known to play a role in the sarcolemma repair of both skeletal muscle fibres and cardiomyocytes. Bulk RNA-seq analysis identified a total of 67 significantly differentially expressed genes (absolute log2FC>1, adj. p<0.05). The comparative analysis of bulk RNA-seq results and publicly available scRNA-seq datasets revealed two commonly upregulated genes in HF fibroblasts or their subclusters, encoding transcription factor FOXF1 (log2FC=3.51, adj.p<0.05) and matrix remodelling-associated protein MXRA5 (log2FC=2.91, adj. p<0.05).

Further in vitro studies on HCFs (n=4) showed that TGF-β upregulated DYSF (p<0.001) and MXRA5 (p<0.01) but downregulated FOXF1 (p<0.05). DYSF silencing in HCFs (n=4) upregulated MXRA5 after 48h of TGF-β stimulation (p<0.05), downregulated ACTA2 (48h and 72h of TGF-β stimulation, p<0.05), and upregulated FOSL2 protein levels in untreated HCFs and 72h after TGF-β stimulation (n=3, p<0.05). MXRA5 knockdown (n=8) resulted in the upregulation of DYSF (p<0.05), ACTA2 (p<0.05) and COL1A1 (p<0.001) in untreated HCFs, and also upregulated DYSF (p<0.01) and COL1A1 (p<0.05) after 48h of TGF-β stimulation. FOXF1 silencing in HCFs (n=8) followed by 48h of TGF-β stimulation downregulated MXRA5 (p<0.01) and ACTA2 (p=0.06), and upregulated DYSF (p<0.001) and COL1A1 (p=0.05). Candidate targets knockdown reduced cell viability in untreated (n=4, DYSF: p<0.01, MXRA5: p<0.001, FOXF1: p<0.01) and TGF-β stimulated (n=4, DYSF: p<0.05, MXRA5: p<0.05, FOXF1: p<0.01) HCFs. ATP levels were decreased in TGF-β-stimulated HCFs after DYSF silencing (n=6, p=0.05).

Conclusion

Based on transcriptomics, proteomics and in vitro analysis of human cardiac fibroblasts, we identified DYSF, MXRA5 and FOXF1 as candidate targets implicated in profibrotic phenotype development, including profibrotic transcription factor FOSL2 regulation. These newly proposed candidates may serve as potential therapeutic targets for the treatment of cardiac fibrosis.

References

[1]Wang, L. et al. Nat. Cell Biol. 2020.

Disclosure of Interests

Ievgeniia Kocherova: None declared, Elena Pachera: None declared, Daria Nurzynska: None declared, Franca Di Meglio: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Przemyslaw Blyszczuk: None declared, Gabriela Kania: None declared.

OP0161 TREATMENT PATTERNS OF IDIOPATHIC INFLAMMATORY MYOPATHIES: RESULTS FROM AN INTERNATIONAL COHORT OF OVER 1,400 PATIENTS

Background

Idiopathic inflammatory myopathies (IIM) are a group of heterogeneous autoimmune disorders with limited standardization of treatment protocols.

Objectives

To evaluate frequency and patterns of various treatments used for IIM based on disease subtype, world region, and organ involvement.

Methods

Cross-sectional data from the international CoVAD self-report e-survey1 was extracted on Sep 14th, 2021. Patient details included demographics, IIM subtypes (dermatomyositis (DM), polymyositis (PM), inclusion body myositis (IBM), antisynthetase syndrome (ASSD), necrotizing myositis (NM) and overlap myositis (OM)), clinical symptoms, disease duration and activity, and current treatments. Treatments were categorized in corticosteroids (CS), antimalarials, immunosuppressants (IS), intravenous immunoglobulins (IVIG), biologics, and others. Typical clinical symptoms (dyspnea, dysphagia) were used as surrogate for organ involvement. Factors associated with IS were analyzed using multivariable logistic regression, adjusting for IIM subtype, demographics, world region, disease activity, and prevalent clinical symptoms (>10%).

Results

In 1418 patients with IIM, median age was 61 years [IQR 49-70], 62.5% were females, median disease duration was 6 years [IQR 3-11], most common subset was DM (32.4%).

The most used treatments were IS (49.4%, including Methotrexate 19.6%, Mycophenolate Mofetil 18.2%, Azathioprine 8.8%, Cyclosporine 2.7%, Tacrolimus 2%, Leflunomide 1.6%, Sulfasalazine 1%, and Cyclophosphamide 0.6%), followed by CS (40.8%), antimalarials (13.8%) and IVIG (9.4%). Biologics were used in 4.3% of patients.

Treatment patterns differed significantly by IIM subtypes with a higher frequency of IS (77.7%) and CS (63.4%) use in ASSD; antimalarials (28.6%) and biologics (9.8%) use in OM and IVIG use in NM (24.6%) (Table 1). Also, treatment patterns were different in regions of the world (Figure 1), with a higher frequency of CS use in Europe (60.5%) and IS use in South America (77.2%). Antimalarials were most used in Asia (19.4%), while IVIG use was most common in Oceania (16.9%). Dyspnea was associated with higher use of IS (69.9%) and CS (65.8%) (p<0.001), whereas dysphagia was negatively associated with IS (39.7%) and CS (32.7%) likely due to a higher proportion in IBM patients reporting dysphagia.

Table 1.

Current Treatments for IIM, Stratified by Disease Subtypes

DermatomyositisPolymyositisInclusion Body MyositisAnti-synthetase syndromeNecrotizing myositisOverlap syndromeAll IIMp-valueNumber of patients459182348148572241418Immunosuppressants*269 (58.6)107 (58.8)39 (11.2)115 (77.7)40 (70.2)130 (58.0)700 (49.4)<0.001Corticosteroids208 (48.0)81 (46.8)32 (9.7)90 (63.4)32 (59.3)103 (50.0)546 (40.8)<0.001Antimalarials99 (21.6)7 (3.8)0 (0.0)25 (16.9)1 (1.8)64 (28.6)196 (13.8)<0.001Intravenous Immunoglobulins54 (11.8)16 (8.8)19 (5.5)10 (6.8)14 (24.6)20 (8.9)133 (9.4)<0.001Biologics**17 (3.7)7 (3.8)0 (0.0)13 (8.8)2 (3.5)22 (9.8)61 (4.3)<0.001Others***6 (1.3)0 (0.0)0 (0.0)1 (0.7)0 (0.0)5 (2,2)12 (0.8)0.098

*Methotrexate (278), Mycophenolate Mofetil (258), Azathioprine (125), Cyclosporine (38), Tacrolimus (28), Leflunomide (23), Sulfasalazine (14), Cyclophosphamide (9)

. **Rituximab (44), Abatacept (5), TNF inhibitors (4), Tocilizumab (3), Belimumab (3), Secukinumab (1)

. ***JAK(10) and PDE4 inhibitors (2)

Multivariable logistic regression analysis showed an association of IS with the IIM subtype (least used in IBM (OR 0.07 [95%CI 0.04-0.13] compared to DM), world region (most used in South America (OR 2.35 [1.12-4.91] compared to North America), active and worsening disease activity (OR 3.49 [1.76-6.91] compared to remission), and some clinical features (dyspnea, fatigue, and muscle weakness).

Conclusion

IIM treatment patterns differ significantly by disease subtypes, world regions and organ involvement, highlighting the need for unified international consensus-driven guidelines.

References

[1]Parikshit S. et al. Rheumatol Int. 2022 Jan;42(1):23–9.

Disclosure of Interests

None declared

POS0914 LATE SKIN FIBROSIS IN SYSTEMIC SCLEROSIS: A STUDY FROM THE EUSTAR COHORT

Background

Skin fibrosis is a cardinal feature of systemic sclerosis (SSc) and associated with significant disability. The early trajectory of skin fibrosis provides insights into the course of the disease including mortality; however, little is known about late skin fibrosis in SSc.

Objectives

The aims of our study were to ascertain the prevalence and characteristics of late skin fibrosis in SSc.

Methods

We developed and tested three conceptual scenarios of late (>5 years after 1st non-RP sign or symptom) skin fibrosis (Figure 1):

Figure 1.

Conceptual models/scenarios of late skin fibrosis in SSc. A: worsening and then improvement (>3 mRSS) during the first 5 years, and then worsened again after 5 years. B: worsening for the first time after 5 years. C: worsening in the first 5 years and stayed high after 5 years (i.e., failure to improve).

A. Worsening and then improvement (>3 mRSS) during the first 5 years, and then worsened again after 5 years.

B. Worsening for the first time after 5 years.

C. Worsening in the first 5 years and stayed high after 5 years (i.e., failure to improve).

We defined skin worsening as modified Rodnan skin score (mRSS) ≥ 5 units or ≥ 25%. Using strict inclusion criteria including complete mRSS, we identified 1,043 (out of 19,115) patients within the EUSTAR database for our analysis. We further restricted analysis within 887 (out of 1,043) patients who had limited (lcSSc) or diffuse cutaneous SSc (dcSSc) at baseline.

Results

One-fifth of patients among the whole cohort (n=208/1043, 19.9%) including in patients with lcSSc or dcSSc at baseline (n=193/887, 21.8%) developed late skin fibrosis. This was largely due to new skin worsening or failure to improve. Patients with lower baseline mRSS and lcSSc were more likely to develop late skin fibrosis. Anti-Scl-70 antibodies (Table 1) were associated with progression from baseline lcSSc to dcSSc, and anticentromere antibodies were protective.

Table 1.

Impact of autoantibody status on progression from baseline limited to diffuse cutaneous SSc (dcSSc).

Skin worsening after 5 years (Scenario B) (n=70)Skin worsening within 5 years and failed to improve after 5-year window (Scenario C) (n=61)Progressed to dcSSc (n=23)Not progressed to dcSSc(n=47)P-valueProgressed to dcSSc (n=37)Not progressed to dcSSc(n=24)P-valueAnticentromere+ve2/22 (9.1%)19/42 (45.2%)0.00346/34 (17.6%)14/21 (66.7%)0.0002-ve20/22 (90.9%)23/42 (54.8%)28/34 (82.4%)7/21 (33.3%)Anti-Scl-70+ve15/23 (65.2%)14/44 (31.8%)0.008822/36 (61.1%)8/23 (34.8%)0.0485-ve8/23 (34.8%)30/44 (68.2%)14/36 (38.9%)15/23 (65.2%)Anti-RNA-Polymerase-III+ve0/12 (0.0%)1/22 (4.5%)1.00000/6 (0.0%)0/14 (0.0%)---ve12/12 (100%)21/22 (95.5%)6/6 (100%)14/14 (100%)

Conclusion

Late skin fibrosis affects approximately 20% of SSc patients >5 years after onset of disease. We have identified different patterns relevant to clinical practice and trial design. Late skin fibrosis is usually due to new worsening or failure of skin to improve. Progression from baseline limited to diffuse cutaneous SSc was associated with anti-Scl-70 antibodies, and anticentromere antibodies were protective. Late skin fibrosis is a neglected manifestation of SSc and warrants further investigation including to determine clinical outcomes and optimal therapeutic strategy.

Acknowledgements

On behalf of EUSTAR collaborators.

Disclosure of Interests

Michael Hughes Speakers bureau: Speaking fees from Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work, Suiyuan Huang: None declared, Juan Jose Alegre Sancho Speakers bureau: Speaking and/or investigational fees from Actelion pharmaceuticals, Eli Lilly, Pfizer, Boehringer Ingelheim, Roche, and GSK, outside of the submitted work, Grant/research support from: Speaking and/or investigational fees from Actelion pharmaceuticals, Eli Lilly, Pfizer, Boehringer Ingelheim, Roche, and GSK, outside of the submitted work, Patricia Carreira: None declared, Merete Engelhart: None declared, Eric Hachulla Speakers bureau: Received consulting fees/meeting fees from Johnson & Johnson, Boehringer Ingelheim, Bayer, GSK, Roche-Chugai, Sanofi-Genzyme; speaking fees from Johnson & Johnson, GSK, Roche-Chugai; and research funding from CSL Behring, GSK, Roche-Chugai and Johnson & Johnson., Consultant of: Received consulting fees/meeting fees from Johnson & Johnson, Boehringer Ingelheim, Bayer, GSK, Roche-Chugai, Sanofi-Genzyme; speaking fees from Johnson & Johnson, GSK, Roche-Chugai; and research funding from CSL Behring, GSK, Roche-Chugai and Johnson & Johnson., Jörg Henes Speakers bureau: Lectures for CHUGAI, Boehringer-Ingelheim, Eduardo Kerzberg: None declared, Maria Rosa Pozzi: None declared, Gabriela Riemekasten: None declared, Vanessa Smith: None declared, Gabriella Szucs: None declared, Marie Vanthuyne: None declared, Elisabetta Zanatta: None declared, Oliver Distler: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Viginia Steen: None declared, Dinesh Khanna Shareholder of: DK has stock options in Eicos Sciences, Inc., Consultant of: Consultant for Acceleron, Amgen, Boehringer Ingelheim, CSL Behring, Chemomab, Genentech/Roche, Horizon, Mitsubishi Tanabe Pharma, Prometheus, Talaris., Grant/research support from: Has received grants from Bayer, BMS, Horizon and Pfizer (to University of Michigan).

POS0383 CLINICAL CHARACTERISTICS AND PROGNOSIS OF PATIENTS WITH SYSTEMIC SCLEROSIS SINE SCLERODERMA: DATA FROM THE INTERNATIONAL EUSTAR DATABASE

Background

LeRoy’s classification defines two main subsets of Systemic Sclerosis (SSc) based on the extent of skin fibrosis: limited cutaneous SSc (lcSSc) with skin thickening sparing the trunk and distal to the elbow and knees, and diffuse cutaneous SSc (dcSSc) with proximal and distal skin thickening. These two subsets notably differ in terms of survival and frequency of visceral involvement, dcSSc being less prevalent but having a higher mortality rate with more frequent visceral manifestations. SSc sine scleroderma (ssSSc) is a third subset initially described by Rodnan et al. and characterized by the absence of skin fibrosis but with the existence of SSc-associated visceral manifestations.

Objectives

This study aimed to characterise the main clinical features of patients with ssSSc in comparison with the lcSSc and dcSSc subsets within the international EUSTAR database.

Methods

All patients from the EUSTAR database fulfilling the ACR2013 or 1980 classification criteria for SSc assessed by the modified Rodnan Skin score (mRSS) at inclusion and with at least one follow-up visit were eligible. Sine scleroderma (ssSSc) was defined by the absence of skin thickening (mRSS=0 and no sclerodactyly) at all available visits. The clinical characteristics of these ssSSc patients were compared to those of patients with lcSSc and dcSSc with similar disease duration at last follow-up visit. Descriptive statistics were applied.

Results

Among the 4263 patients fulfilling the inclusion criteria, 376 (8.8%) were classified as ssSSc. Among them, 40.3% had puffy fingers, 39.4% had interstitial lung disease (ILD), 1.6% had a history of scleroderma renal crisis at inclusion visit. At last available visit, in comparison with 708 lcSSc and 708 dcSSc with the same disease duration, ssSSc patients had a lower prevalence of previous or current digital ulcers (28.2% versus 53.1% in lcSSc (P<0.001) and 68.3% in dcSSc (P<0.001)), of joint synovitis (16.9% versus 24.3% in lcSSc (P<0.01) and 30.8% in dcSSc (P<0.0001)), and of elevated sPAP on echocardiogram (15.2% versus 23.9% in lcSSc (P<0.01) and 28.7% in dcSSc (P<0.0001)). Despite similar disease duration, disease activity at follow up visit (assessed by the EScSG disease activity index 2001 and 2016) was lower in ssSSc in comparison with lcSSc and dcSSc. By contrast, the prevalence of ILD was almost similar in ssSSc and lcSSc (49.8% and 57.1% (P=0.03)) but significantly higher in dcSSc (75.0%, P<0.0001). Based on forced vital capacity, ILD was less severe in ssSSc in comparison with the other subsets (mean FVC 100% (SD=22)(%pred) versus 93% (SD=21) in lcSSc and 82% (SD=23) in dcSSc (P<0.0001 for both)). Anti-centromere antibodies were most represented in ssSSc (61.7% versus 41.9% in lcSSc (P<0.0001) and 16.3% in dcSSc (P<0.0001), whereas the opposite distribution was observed for anti-Scl70 antibodies. Survival was significantly higher in ssSSc patients compared to lcSSc (P<0.05) and dcSSc (P<0.0001).

Conclusion

This study highlights that ssSSc patients account for almost 10% of SSc patients with milder disease severity compared to both lcSSc and dcSSc.

Acknowledgements

The authors thank all EUSTAR collaborators

Disclosure of Interests

Alain LESCOAT: None declared, Suiyuan Huang: None declared, Patricia Carreira: None declared, Elise Siegert: None declared, Jeska de Vries-Bouwstra: None declared, Jörg H.W. Distler: None declared, Vanessa Smith: None declared, Francesco Del Galdo: None declared, Branimir Anic: None declared, Nemanja Damjanov: None declared, Simona Rednic: None declared, Camillo Ribi: None declared, DOMNIQUE FARGE: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Armando Gabrielli: None declared, Oliver Distler: None declared, Dinesh Khanna: None declared, Yannick Allanore: None declared

POS0387 RISK STRATIFICATION APPROACHES PERFORM DIFFERENTLY IN SSc-ASSOCIATED PAH IN EUSTAR

Background

Pulmonary arterial hypertension (PAH) is a major clinical challenge in systemic sclerosis (SSc), and is associated with high mortality. Risk stratification provides an estimate for individual patient risk of 1-year mortality. The aim is to detect patients with the worst prognosis to optimize management strategies. Nine risk stratification approaches have been proposed in PAH, but have not been validated in SSc-PAH.

Objectives

To assess four risk stratification models and their performance to predict 1- and 3- year mortality and to identify the best risk assessment approach for SSc-PAH.

Methods

We included all patients with SSc diagnosed with PAH by right heart catheterization (RHC) from the European scleroderma trial and research (EUSTAR) database from 2001 to February 2021. PAH was defined as mean pulmonary arterial pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure (PAWP) ≤15mmHg, and pulmonary vascular resistance (PVR) >3 Wood units (WU) in the absence of significant interstitial lung disease. We applied four different approaches for risk stratification at time of PAH diagnosis. Risk parameters included New York Heart Association (NYHA) class, 6-minute walk distance (6MWD), NT-proBNP or BNP, and echocardiographic and hemodynamic parameters with cut-off values based on the 2015 ESC/ERS Guidelines. Model 1 and 2 stratified patients into low, intermediate and high-risk categories; while Model 3 and 4 stratified the patients into four categories (low, intermediate-low, intermediate-high and high).

Model 1: Patients with ≥ 1 high-risk parameter were considered at high risk; with ≥ 1 intermediate-risk parameter at intermediate risk, otherwise at low risk1

Model 2: Each variable was graded from 1 to 3 representing low to high risk. The mean of available risk parameters was rounded to the nearest integer to define the risk category2

Model 3: Equals Model 2, but the intermediate risk group was divided into intermediate-low and intermediate-high based on the mean score3

Model 4: Stratifies patients into four risk categories based on the proportion of low-risk parameters3

We performed analysis of 1- and 3- year mortality in patients with a minimum follow-up of 1 and 3 years, respectively.

Results

Of 911 patients who conducted RHC, 273 (30%) were diagnosed with SSc-PAH according to the inclusion criteria (Table 1). Median follow-up time was 2.8 years (IQR 1.3-5.3). The models varied in their ability to predict mortality (Figure 1). Model 1 and 4 either over- or underestimated mortality. Model 2 stratified patients according to the expected 1-year mortality of <5%, 5-10% and >10% suggested by the ESC/ERS Guidelines. Model 3, which divided the intermediate risk group in two different risk groups, segregated the risk of mortality further within this group.

Table 1.

Demographic and clinical characteristics of patients segregated by risk stratification (Model 3)

NAll patients (n=273)Low-risk (n=78)Intermediate-low (n=118)Intermediate-high (n=56)High-risk (n=21)Age, years (SD)27365 (10.7)65 (10.3)65 (10.7)65 (10.8)67 (12.8)Female sex, n (%)273230 (84)64 (82)98 (83)48 (86)20 (95)lcSSc, n (%)263221 (84)60 (80)99 (86)47 (90)15 (71)NYHA 3 or 4, n (%)261155 (59)12 (16)75 (68)49 (89)19 (95)NT-proBNP, pg/ml (IQR)1111941 (230-1485)215 (103-377)763 (325-1418)1926 (1051-5681)3314 (1129-6553)6MWD, m (SD)196321 (124.1)404 (119.7)314 (99.9)262 (128.6)215 (96.0)RHC:- mPAP, mmHg (SD)27340 (11.0)35 (8.8)41 (11.5)41 (10.8)45 (11.6)- PAWP, mmHg (SD)2739 (3.2)9 (3.0)9 (3.4)9 (3.2)8 (3.1)- Cardiac index, l/min/m2(SD)2602.8 (0.8)3.2 (0.7)2.7 (0.8)2.6 (1.0)2.0 (0.5)- PVR, WU (SD)2737.4 (4.1)5.3 (2.8)7.9 (4.0)7.9 (4.2)11.3 (4.7)Figure 1.

1- and 3-year mortality according to risk category in the four different models

Conclusion

Model 3 provides signals for a better risk stratification of patients with newly diagnosed SSc-PAH, with progressively increasing mortality across the categories. This may provide guidance for optimized management in clinical practice.

References

[1]Hoffmann-Vold, Rheum 2018

[2]Kylhammar, Eur Heart J 2018

[3]Kylhammar, ERJ open 2021

Acknowledgements

The authors thank all EUSTAR collaborators.

Disclosure of Interests

Hilde Jenssen Bjørkekjær: None declared, Cosimo Bruni Speakers bureau: Actelion, Consultant of: Boehringer-Ingelheim, Patricia Carreira: None declared, Paolo Airò Speakers bureau: Boehringer Ingelheim, Bristol-Myers-Squibb, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Janssen, CSL Behring, Carmen Pilar Simeón-Aznar Speakers bureau: Janssen, Boehringer Ingelheim and MSD, Consultant of: Janssen, Boehringer Ingelheim, Marie-Elise Truchetet: None declared, Alessandro Giollo: None declared, Alexandra Balbir-Gurman: None declared, Mickael Martin: None declared, Christopher P Denton Speakers bureau: Boehringer Ingelheim; Janssen, Consultant of: Boehringer Ingelheim; GSK; Corbus; Sanofi; Roche; Horizon; CSL Behring; Acceleron, Grant/research support from: CSL Behring; Horizon; GSK; Servier, Armando Gabrielli: None declared, Håvard Fretheim Consultant of: Bayer, GSK, Actelion, Imon Barua: None declared, Helle Bitter Speakers bureau: Boehringer Ingelheim, Øyvind Midtvedt: None declared, Kaspar Broch: None declared, Arne Andreassen: None declared, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Gabriela Riemekasten: None declared, Ulf Müller-Ladner: None declared, Marco Matucci-Cerinic: None declared, Ivan Castellví: None declared, Elise Siegert: None declared, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim

OP0199 RADIOMIC SIGNATURES REFLECT TREATMENT RESPONSE TO NINTEDANIB IN PRECLINICAL LUNG FIBROSIS MODEL

Background

Responses to anti-fibrotic drugs in preclinical disease models are difficult to quantify by histological analysis of single tissue sections. Quantitative in-depth analysis of imaging data, termed “radiomics”, may represent a more reliable and accurate measure of treatment response since the pathology of the whole organ is captured.

Objectives

To study the potential of µCT-derived radiomic features to reflect response to Nintedanib in the bleomycin (BLM)-induced murine model of fibrosing interstitial lung disease.

Methods

All C57BL/6J mice from both study groups were intratracheally instilled with 2 U/kg BLM on day 0 to induce lung fibrosis. Nintedanib was administered daily by gavage at 60 mg/kg for two weeks starting from day 7 (n=15). Controls received equivalent treatment with vehicle-only (n=19). Whole lung µCT scans (SkyScan 1176, Bruker) of each animal were acquired at baseline (day 0), pre-treatment (day 7), and post-treatment (day 21). The Ashcroft score was assessed on Sirius Red stained lung sections post-treatment. Lung volumes in µCTs were defined semi-automatically in MIM Software (6.9.2), followed by extraction of radiomic features with our in-house developed software Z-Rad (7.3.1). Each data set contained 1’386 features, describing image characteristics with histogram, texture, and wavelet functions. Data pre-processing involved removal of features sensitive to intra- and interobserver delineation variability (ICC<0.75), highly correlated features (Pearson’s r>0.95), and features not significantly changing between days 0 and 7 (p>0.05). Agglomerative clustering of radiomic temporal trajectories was performed on the Nintedanib group to identify distinct feature clusters. The identified feature sets were then used to plot average feature value trajectories for both study groups in each cluster. To identify features significantly different between a) Nintedanib vs. control, and b) pre- vs. post-treatment, Mann-Whitney U and Wilcoxon signed-rank tests were used, respectively. Samples were pooled from two independent experiments.

Results

Evaluation of tissue sections did not show a significant treatment-induced reduction of fibrosis with average Ashcroft scores of 3.7 (±1.2 s.d.) and 3.4 (±1.6 s.d.) in Nintedanib and control samples, respectively (p>0.05). Radiomics data analysis revealed two feature clusters in Nintedanib samples, composed of 52 features (cluster 1) and 96 features (cluster 2), the trajectories of which were then plotted for both study groups. In cluster 1, feature value trajectories significantly decreased in both Nintedanib and control group between pre-and post-treatment (p<0.001), whereas feature values in cluster 2 remained flat (p>0.05). Importantly, Nintedanib-treated mice displayed a much more pronounced feature value decrease post-treatment in cluster 1 compared to the control group (p<0.05). Here, feature values post-treatment resembled pre-disease baseline conditions in the Nintedanib group (p>0.05), whereas the control group remained significantly different from baseline (p<0.01). Cluster 1 was composed of 6 histogram, 11 texture, and 35 wavelet features, emphasizing the role of high-dimensional metrics for the detection of differences.

Conclusion

Histological quantification of lung fibrosis accounts only for a small fraction of the whole pathology in a spatially heterogeneous disease. We demonstrated that µCT-derived radiomic features identified significant differences on imaging level following Nintedanib treatment, which we could not reliably detect on tissue level using Ashcroft scoring. These findings hold great potential for the development of novel readouts for improved stratification of anti-fibrotic treatment effects in preclinical models.

Acknowledgements

This study received funding support from the Swiss Lung Association.

Disclosure of Interests

David Lauer Shareholder of: Roche (no relation to project), Employee of: Former employee of Roche (no relation to project), Janine Schniering: None declared, Hubert Gabrys: None declared, Malgorzata Maciukiewicz: None declared, Matthias Brunner: None declared, Oliver Distler Speakers bureau: Speaker fees in the area of systemic sclerosis and related complications from Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Consultancies in the area of systemic sclerosis and its complications with Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Grant/research support from Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Thomas Frauenfelder: None declared, Stephanie Tanadini-Lang: None declared, Britta Maurer Speakers bureau: Received speaker fees from Boehringer-Ingelheim as well as congress support from Medtalk, Pfizer, Roche, Actelion, Mepha, and MSD, Consultant of: Consultancies with Novartis, Boehringer Ingelheim, Janssen-Cilag. Has a patent mir-29 for the treatment of systemic sclerosis issued (US8247389, EP2331143), Grant/research support from: Had grant/research support from AbbVie, Protagen, Novartis Biomedical Research.

OP0095 SINGLE-CELL RNA SEQUENCING REVEALS POTENT ANTI-INFLAMMATORY AND ANTIFIBROTIC ACTIVITIES OF DIMETHYL-ALPHA-KETOGLUTARATE ON EXPLANTED SKIN FROM PATIENTS WITH SYSTEMIC SCLEROSIS

Background

Activated fibroblasts are the main drivers of skin fibrosis in SSc. We have recently identified dimethyl alpha-ketoglutarate (dm-aKG) as a potential repressor of myofibroblast differentiation and profibrotic activity in cultured skin fibroblasts.

Objectives

To further analyse the clinical translation of our findings by investigating the antifibrotic capacity of dm-aKG on explanted skin biopsies from SSc patients.

Methods

We cultured forearm punch skin biopsies from SSc patients (n=10) for 24h ex vivo in the presence/absence of 6 mM dm-aKG. Thereafter, skin biopsies (n=4) were dissociated into single cells using a combined mechanical-enzymatic dissociation protocol, followed by single cell (sc)RNA-seq library preparation (10x Genomics) and sequencing (Illumina, NovaSeq6000, 50,000 reads/cell). We mapped the scRNA-seq reads to the reference genome GRCh38.p13 and analysed the data with R/Bioconductor tools. We deconvoluted cell types in bulk skin transcriptomes from SSc cohorts (GSE: 45485, 59785, 9285, 32413) using human skin scRNA-seq data1. The secretion of IL-6, procollagen-1, PRO-C1 (N-terminal type I collagen pro-peptide), C1M (MMP-degradation fragment of type I collagen), and fibronectin (FBN-C) from cultured skin (n=10) was measured in supernatants by ELISA. We analysed gene and protein expression in TGFβ-activated healthy and SSc dermal fibroblasts (DF, n=10) treated or not with dm-aKG using qPCR, Western blot and ELISA. Contractile properties of DF were assessed by gel contraction assay. Traction forces generated by DF were determined by reference-free traction force microscopy.

Results

Dissociated cultured SSc skin exhibited comparable cell yield and viability in the presence (20,203; 89%) and absence (25,280; 93%) of dm-aKG, respectively. scRNA-seq skin analysis included 20,869 high quality single cell profiles segregating into 10 distinct skin cell populations (Figure 1A). This analysis demonstrated decreased proportion of fibroblasts and increased proportion of keratinocytes in dm-aKG treated skin (p<0.05; Figure 1B). Among skin cell types, skin fibroblasts exhibited the largest amount of differentially expressed genes upon dm-aKG treatment (44%, n=779, x-fold>0.5, FDR<0.05), suggesting that these cells are key targets of dm-aKG therapy in SSc skin. We identified inflammatory/cytokine signalling (hub genes IL6, STAT1) and extracellular matrix (ECM) organization (hub genes MMP1, ITGB3) as top downregulated biological processes in fibroblasts in dm-aKG treated SSc skin (Figure 1C), coinciding with a decreased abundance of proinflammatory skin fibroblast subpopulation. Specifically, these cells were identified as the main source of IL6 (Figure 1D) and were enriched in SSc skin as revealed by deconvolution analysis of skin transcriptomes. Furthermore, dm-aKG reduced the secretion of IL-6, procollagen-1 and C1M, but not pro-C1 and FBN-C, from cultured skin explants. In cultured DF, dm-aKG blocked the inflammatory (IL-6, pSTAT3), profibrotic (aSMA, Fibronectin, Procollagen-1, Pro-C1) and contractile activities, and significantly diminished traction forces exerted by DF on the matrix substrate.

Figure 1.

scRNA-seq – comparison of untreated and dm-aKG treated paired skin biopsies. (A) UMAP plot with annotated skin cells, (B) differential abundance of main skin cell types, (C) volcano plot of DE genes with top downregulated gene ontology (GO) pathways in dm-aKG treated skin fibroblasts, (D) IL6 expression in untreated (blue) and treated (pink) skin fibroblasts.

Conclusion

Dm-aKG broadly interferes with inflammatory and ECM organizational activities of skin fibroblasts in culture and in explanted skin from SSc patients. These results confirm that dm-aKG might represent a potential new therapeutic approach for efficient targeting of skin inflammation and fibrosis in SSc.

References

[1]He H et al. J Allergy Clin Immunol 2020

Acknowledgements

This work was supported by a research grant from FOREUM Foundation for Research in Rheumatology and University Medical Centre Ljubljana.

Disclosure of Interests

Blaž Burja: None declared, Dominique Paul: None declared, Reto Gerber: None declared, Sam G. Edalat: None declared, Muriel Elhai Speakers bureau: BMS, Elena Pachera: None declared, Rahel S. Zingg: None declared, Francesca Michela Pramotton: None declared, Sofie Falkenløve Madsen: None declared, Kristina Buerki: None declared, Giampietro Costanza: None declared, Michael Whitfield: None declared, Anne-Christine Bay-Jensen: None declared, Snežna Sodin-Šemrl: None declared, Matija Tomsic: None declared, Gabriela Kania: None declared, Hubert Rehrauer: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Ziga Rotar: None declared, Mark Robinson: None declared, Katja Lakota: None declared, Mojca Frank Bertoncelj: None declared.

POS0877 INTERSTITIAL LUNG DISEASE IN ANTI-U1RNP SYSTEMIC SCLEROSIS PATIENTS: A EUROPEAN SCLERODERMA TRIALS AND RESEARCH (EUSTAR) ANALYSIS

Background

Interstitial lung disease (ILD) has become the leading cause of mortality in systemic sclerosis (SSc) patients (1). The presence of anti-U1RNP antibodies is primarily associated with mixed connective tissue disease (MCTD), however these autoantibodies may be found in up to 10% of SSc patients (2). A recent large multicenter study showed that the presence of anti-U1RNP antibodies was independently associated with more severe disease in SSc patients. However, so far, little is known about the influence of anti-U1RNP antibodies specifically on lung outcomes in SSc-ILD patients.

Objectives

To describe the clinical features, outcomes and prognosis of anti-U1RNP SSc-ILD patients.

Methods

SSc patients with available data on their autoantibody profile were identified from the EUSTAR database. Those with ILD identified by high-resolution chest tomography (HRCT) were included for analysis. Baseline demographic and disease features were compared between anti-U1RNP positive and anti-U1RNP negative patients. For the longitudinal part in patients with repeated lung function tests, the mean annual decline in %predicted forced vital capacity (%pFVC) was compared between the two groups. Predictors associated with death of any cause or severe ILD progression, defined as a drop >10% in %pFVC/year, were evaluated in SSc-ILD patients with or without U1RNP. Mild progression was defined as a loss of 5-10% in %pFVC/year. Demographic and clinical parameters were compared between patients positive and negative for anti-U1RNP antibodies in univariate analysis. Associations between anti-U1RNP status and lung involvement were tested in multivariate logistic regression models.

Results

A total of 5676 SSc-ILD patients were included for the analysis, among which 320 (5.6%) were positive for anti-U1RNP antibodies. Mean age was 56.4±13.5 years and 4645 (81.8%) were women.

Anti-U1RNP+ SSc-ILD patients had more frequently limited cutaneous SSc (52.5% vs 39.8%, p<0.001), higher frequency of joint synovitis (20.0% vs 12.9%, p<0.001) and myositis (22.2% vs 18.2%, p<0.03) and lower incidence of scleroderma renal crisis (0.3% vs 2.0%, p=0.02).

Anti-U1RNP+ patients had a baseline lower mean %pFVC (81.1% vs 85.3%, p=0.002) and lower mean %predicted diffusing capacity for carbon monoxide (%pDLCO) (58.9% vs 60.2%, p=0.004) than anti-U1RNP- SSc-ILD patients. No significant differences were found at baseline HRCT, including lung involvement >20% (4.4 vs 4.2%%, p=0.39), or the presence of ground glass opacities (38.1% vs 33.6%, p=0.14).

A total of 2697 (50.3%) patients with SSc-ILD had at least one FVC measurement available during a mean follow-up of 20.8±20.5 months. Mean expected decline in %FVC per year was not different between U1RNP positive and negative patients (-0.21% vs -0.68%, p=0.70). Mortality or severe ILD progression was not statistically different between the two groups (35 (21.6%) vs 677 deaths (26.7%), p=0.43, and 23 (14.0%) vs 283 severe progressors (11.0%), p=0.25, respectively). Mild ILD progression was also not statistically different between the two groups (11.0% vs 10.0%, p=0.20). The proportion of patients with FVC<80% at last follow-up was similar between U1RNP positive and negative patients (50.6% vs 44.3%, p=0.13).

Conclusion

Our results from the EUSTAR database show that SSc patients positive for anti-U1RNP antibodies have more impaired baseline lung function but similar rate of progression during follow-up. This suggests that early stages might be important in RNP+ SSc-ILD patients who may require specific management and follow-up.

References

[1]Hoffmann-Vold A-M, Allanore Y, Alves M, Brunborg C, Airó P, Ananieva LP, et al. Progressive interstitial lung disease in patients with systemic sclerosis-associated interstitial lung disease in the EUSTAR database. Ann Rheum Dis. 28 sept 2020;

[2]Asano Y, Ihn H, Yamane K, Kubo M, Tamaki K. The Prevalence and Clinical Significance of Anti-U1 RNA Antibodies in Patients with Systemic Sclerosis. Journal of Investigative Dermatology. fevereiro 2003;120(2):204‑10.

Disclosure of Interests

Gonçalo Boleto: None declared, Corrado Campochiaro: None declared, Anna-Maria Hoffmann-Vold: None declared, Armando Gabrielli: None declared, Oliver Distler Consultant of: OD has/had consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Jerôme Avouac: None declared, Yannick Allanore Paid instructor for: YA reports personal fees from Actelion, Bayer, BMS, Boehringer, Curzion, Inventiva, Roche and Sanofi and research grants from Inventiva, Sanofi and Alpine Immunosciences.

POS0854 BASELINE CHARACTERISTICS OF PATIENTS WITH IMPROVEMENT OR PROGRESSION OF SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE (SSc-ILD) DURING THE SENSCIS TRIAL

Background

The course of SSc-ILD is variable, and may include periods of stability or even improvement in forced vital capacity (FVC) as well as periods of decline.

Objectives

To investigate the baseline characteristics of patients with SSc-ILD in the placebo group of the SENSCIS trial whose ILD improved or progressed over 52 weeks.

Methods

The SENSCIS trial enrolled patients with SSc with first non-Raynaud symptom in the prior ≤7 years, extent of fibrotic ILD on high-resolution computed tomography (HRCT) ≥10% and FVC ≥40% predicted. Patients who had been taking a stable dose of mycophenolate for ≥6 months were allowed to participate. We investigated the baseline characteristics of patients in the placebo group whose ILD showed improvement (absolute increase in FVC ≥5% predicted), stability (absolute decline or increase in FVC <5% predicted), progression (absolute decline in FVC ≥5% predicted), or significant progression (absolute decline in FVC ≥10% predicted) over 52 weeks. P-values based on ANOVA or Chi-squared tests were used to compare the baseline characteristics of the patients who showed improvement, stability and progression.

Results

Of 288 patients, 21 (7.3%) showed improvement, 166 (57.6%) stability, and 101 (35.1%) ILD progression, of whom 37 (12.8% of all patients) had significant ILD progression over 52 weeks. Most baseline characteristics were similar across the groups based on progression, but there were differences in DLCO % predicted (p=0.02) and in the proportion of patients taking mycophenolate (p=0.09) among patients who showed improvement, stability and progression (Table 1).

Table 1.

Baseline characteristics of patients in the placebo group of the SENSCIS trial in subgroups based on course of SSc-ILD over 52 weeks.

Improvement (n=21)Stability (n=166)Progression (n=101)Significant progression (n=37) (subset of Progression)P-value for comparison of Improvement, Stability, ProgressionAge, years55.9 ± 12.053.2 ± 12.653.1 ± 12.855.3 ± 11.80.64Female71.475.970.373.00.59Years since first non-Raynaud symptom3.7 ± 1.73.5 ± 1.73.5 ± 1.93.6 ± 1.90.81Diffuse cutaneous SSc47.649.453.556.80.78Anti-topoisomerase I antibody positive61.958.466.356.80.44High sensitivity C-reactive protein, mg/L5.1 ± 8.97.8 ± 23.05.6 ± 9.94.2 ± 4.40.62Modified Rodnan skin score9.3 ± 7.310.5 ± 8.411.9 ± 9.712.7 ± 11.30.29History of gastroesophageal reflux disease (GERD)76.272.978.278.40.62Extent (%) of fibrotic ILD on HRCT*26.4 ± 16.235.5 ± 20.436.6 ± 21.840.8 ± 23.50.12Presence of honeycombing on HRCT14.316.815.526.50.94Presence of ground glass opacities on HRCT81.086.689.784.80.51FVC % predicted77.1 ± 18.071.7 ± 17.273.3 ± 15.274.2 ± 14.80.33DLco % predicted61.5 ± 14.953.4 ± 14.851.1 ± 15.147.3 ± 14.50.02Taking mycophenolate71.448.245.535.10.09

Data are mean ± SD or % at baseline. Missing data were excluded. *Assessed visually in whole lung to nearest 5%. The assessment did not include pure (non-fibrotic) ground glass opacities.

Conclusion

These findings suggest that in the SENSCIS trial, patients who had higher DLCO % predicted or who were taking mycophenolate at baseline were less likely to show progression of SSc-ILD over 52 weeks.

Acknowledgements

The SENSCIS trial was funded by Boehringer Ingelheim. Oliver Distler was a member of the SENSCIS trial Steering Committee.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Paid instructor for: Boehringer Ingelheim, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Eric Hachulla Speakers bureau: Johnson & Johnson, GlaxoSmithKline, Roche-Chugai; and research funding from CSL Behring, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Consultant of: Bayer, Boehringer Ingelheim, GlaxoSmithKline, Johnson & Johnson, Roche-Chugai, Sanofi-Genzyme, Grant/research support from: GlaxoSmithKline, Roche-Chugai, Sanofi-Genzyme, Ariane Herrick Speakers bureau: Janssen, Consultant of: Arena, Boehringer Ingelheim, Camurus, CSL Behring, Gesynta, Grant/research support from: Gesynta, Teng Moua: None declared, Gabriela Riemekasten Speakers bureau: Boehringer Ingelheim, Janssen, Consultant of: Boehringer Ingelheim, Janssen, Madelon Vonk Speakers bureau: Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Janssen, MSD, Novartis, Roche, Consultant of: Boehringer Ingelheim, Corbus, Janssen, Grant/research support from: Boehringer Ingelheim, Ferrer, Galapagos, Janssen, Alexandra James Employee of: Alexandra James is an employee of Elderbrook solutions GmbH that is contracted by Boehringer Ingelheim, Margarida Alves Employee of: Margarida Alves is employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape

, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie

, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe

POS0406 CHARACTERISATION OF ENHANCER RNAs IN RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLASTS

Background

Rheumatoid arthritis synovial fibroblasts (SF) exhibit a prolonged histone 3 lysine 27 acetylation (H3K27ac) after stimulation with TNF, leading to a sustained inflammatory response. Enhancer RNAs (eRNAs) are short-lived non-coding RNAs transcribed from cell type-specific H3K27ac-marked enhancers that facilitate the transcription of their linked coding genes. The interrelation of eRNAs and their linked coding genes in SF has not been studied yet.

Objectives

To analyze the expression and regulation of inflammatory eRNAs in SF.

Methods

The expression of eRNAs in SF (n=9), stimulated with TNF (24h; 10 ng/µl) or left untreated, was detected by cap analysis of gene expression followed by sequencing (CAGEseq). To further investigate eRNA expression in SF, the expression of selected eRNAs and their linked coding genes (CXCL1, CCL20, IL6, CCL2, CXCL12, IL8) was analyzed by real-time PCR in SF that were stimulated with TNF (1, 3, 6, 24h; 10 ng/µl), IL1 (1, 24h; 1 ng/ml), or the Toll-like receptor agonists Pam3 (1, 24h; 1 ng/ml), pIC (1, 24h; 10 μg/ml) and LPS (1, 24h; 100 ng/µl). Samples containing the untranscribed RNA were measured in parallel. To study eRNA regulation, SF were treated with the bromodomain inhibitor I-BET (1 µM; 24h), or silenced for the histone acetyltransferases CBP and p300 by transfection of antisense LNA gapmeRs (12.5 nM) prior to stimulation with TNF (1, 24h).

Results

We have selected four potential eRNAs for CCL2 and IL8, three for CXCL12, two for IL6 and CXCL1 and one for CCL20 from CAGEseq analysis. They were located upstream (eCCL2#1, eCCL2#2, eCXCL1#2, eCXL12#3, eIL6#1 + 2, eIL8#1-4), downstream (eCCL2#3, eCCL2#4, eCXCL1#1, eCXL12#1) and intronic (eCCL20, eCXL12#2) at distances between 300 bp to 35.6 kb relative to the transcription start sites of the corresponding coding genes. None of the eRNAs was present in all nine samples in CAGEseq data sets, indicating a patient-dependent variability in eRNA expression. The majority of eRNAs were not detected in unstimulated SF, with the exception of eRNAs for CXCL12. By performing TNF time course experiments (Figure 1), we have detected different patterns of eRNAs: (a) eRNAs, that peaked at 1h (eCCL20, eIL8#2, eCCL2#1), (b) at 6h (eCXCL1#1), (c) or at 24h (eIL8#1, eIL8#3, eIL8#4, eCXCL1#2) after stimulation, (d) eRNAs that were stably expressed over the time points (eCCL2#2, 3, 4), and (e) eRNAs that were down regulated by TNF stimulation (eCXCL12#1, eCXCL12#3). All inflammatory stimuli induced eRNA expression in SF, with LPS and IL1, followed by TNF, being the most potent inducers of eRNAs. I-BET suppressed the TNF-induced expression of all eRNAs tested. The effects on the expression of eRNAs after silencing of p300 but not of CBP mirrored to a large extent those of the respective coding genes.

Figure 1.

Conclusion

In SF, the expression of some eRNAs is maintained for up to 24h, contradicting previous reports that eRNAs are short-lived. Our data suggest that different eRNAs orchestrate the early and sustained expression of cytokines and chemokines in SF. eRNA expression is controlled by p300 and BET bromodomain proteins.

Disclosure of Interests

Larissa Moser: None declared, Miranda Houtman: None declared, Oliver Distler Consultant of: Abbvie, Britta Maurer Speakers bureau: Boehringer-Ingelheim, Consultant of: Novartis, Boehringer Ingelheim, Janssen-Cilag, Grant/research support from: AbbVie, Protagen, Novartis Biomedical Research, Caroline Ospelt: None declared, Kerstin Klein Grant/research support from: Novartis Foundation for biomedical research (2019)

POS0853 EFFECTS OF NINTEDANIB ON CIRCULATING BIOMARKERS IN SUBJECTS WITH SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE (SSc-ILD)

Background

In the SENSCIS trial in subjects with SSc-ILD, nintedanib reduced the rate of decline in forced vital capacity (FVC) over 52 weeks by 44% compared with placebo.

Objectives

To investigate the effects of nintedanib on circulating biomarkers of extracellular matrix (ECM) turnover, epithelial injury and inflammation in the SENSCIS trial.

Methods

Subjects had SSc with first non-Raynaud symptom in the prior ≤7 years, extent of fibrotic ILD on high-resolution computed tomography (HRCT) ≥10% and FVC ≥40% predicted. Patients were randomised to receive nintedanib or placebo stratified by anti-topoisomerase I antibody (ATA). Blood samples were taken at baseline and at weeks 4, 24 and 52. Fold changes in adjusted mean levels of circulating biomarkers were analyzed using a linear mixed model for repeated measures. Data were log10 transformed before analysis and estimates of change from baseline were back-transformed.

Results

A total of 576 subjects received trial drug (288 nintedanib, 288 placebo). A transient increase in fold change from baseline in C-reactive protein (CRP) (a marker of inflammation) was observed in subjects who received nintedanib versus placebo at week 4. After an initial increase at week 4 in the fold change from baseline in CRP degraded by MMP-1/8 (CRPM) (a marker of ECM turnover), a trend to decreasing levels was observed in subjects who received nintedanib compared with placebo at week 52. Decreases in the fold change from baseline in collagen 3 degraded by MMP-9 (C3M) and N-terminal propeptide of type VI collagen (pro-C6) (markers of ECM turnover) were observed in subjects who received nintedanib compared with placebo from week 24 and week 4, respectively. A decrease in fold change from baseline in Krebs von den Lungen-6 (KL-6) (a marker of epithelial injury) was observed in subjects who received nintedanib versus placebo at week 52. A decrease in fold change from baseline in cancer antigen 125 (CA-125) (a marker of epithelial injury) was observed in subjects who received nintedanib versus placebo from week 4 (Figure 1).

Conclusion

Data from the SENSCIS trial suggest that nintedanib reduced circulating levels of markers of ECM turnover and epithelial injury in subjects with SSc-ILD.

Acknowledgements

The SENSCIS trial was funded by Boehringer Ingelheim. Masataka Kuwana, Toby M Maher and Oliver Distler were members of the SENSCIS trial Steering Committe.

Disclosure of Interests

Shervin Assassi Speakers bureau: On speaker bureau for Integrity Continuing Education, Consultant of: Abbvie, AstraZeneca, Boehringer Ingelheim, CSL Behring, Novartis, Grant/research support from: Boehringer Ingelheim, Janssen, Masataka Kuwana Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Tanabe-Mitsubishi, Ono Pharmaceuticals, Consultant of: AstraZeneca, Boehringer Ingelheim, Corbus, Mochida

Kissei, Grant/research support from: Boehringer Ingelheim, MBL, Ono Pharmaceuticals, Christopher P Denton Speakers bureau: Boehringer Ingelheim, Janssen, Consultant of: Abbvie, Acceleron, Boehringer Ingelheim, Corbus, CSL Behring, GlaxoSmithKline, Roche, Grant/research support from: ARXX Therapeutics, GlaxoSmithKline, Horizon Therapeutics, Servier, Toby Maher Speakers bureau: Boehringer Ingelheim, Galapagos, Genentech, Consultant of: AstraZeneca, Bayer, Blade Therapeutics, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Galecto, GlaxoSmithKline R&D, IQVIA, Pliant, Respivant, Roche, Theravance and Veracyte, Grant/research support from: AstraZeneca, GlaxoSmithKline, Claudia Diefenbach Employee of: Claudia Diefenbach is an employee of Boehringer Ingelheim, Carina Ittrich Employee of: Carina Ittrich is an employee of Boehringer Ingelheim, Martina Gahlemann Employee of: Martina Gahlemann is an employee of Boehringer Ingelheim, Oliver Distler Speakers bureau: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Speaker fee: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Consultancy fee: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur

OD has/had relationships with the following companies in the area of potential treatments for arthritides in the last three calendar years:

Consultancy fee: Abbvie, Grant/research support from: OD has/had relationships with the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years:

Research Grants: Boehringer Ingelheim, Kymera, Mitsubishi Tanabe,

POS0140 PREDICTING OUTCOMES IN SYSTEMIC SCLEROSIS: STRATIFICATION BY AUTO-ANTIBODIES OUTPERFORMS CUTANEOUS SUBSETTING IN THE EUSTAR COHORT

Background

Risk-stratification is key in a heterogeneous disease like systemic sclerosis (SSc). Until now, SSc patients are stratified according to the extent of skin involvement into limited cutaneous, diffuse cutaneous and sine scleroderma subtypes. However, this classification remains inaccurate to capture disease heterogeneity. Autoantibodies are found in more than 90% of the patients and can be detected before onset of the disease. Among them, three predominant and specific antibodies are used: anti-centromere, anti-Scl70 and RNA polymerase III antibodies.

Objectives

To compare the performances of stratification into LeRoy’s cutaneous subtypes versus autoantibody status in SSc versus combination of cutaneous subtypes and autoantibodies status.

Methods

Patients from the EUSTAR database were classified either as (i) limited cutaneous, diffuse cutaneous or sine scleroderma (based on the recording made by the treating physician) or (ii) according to autoantibodies with the following subclassifications: (1) no specific autoantibodies, (2) isolated ANA, (3) anti-centromere antibodies, (4) anti-Scl70 antibodies and (5) anti-RNA polymerase III antibodies or (iii) according to combination of cutaneous subset and auto-antibodies. The respective performance of each model to predict overall survival (OS), progression-free survival (PFS), disease progression and different organ involvements was assessed and the three models were compared by the area under the receiver operating characteristic curve (AUC 95%CI) and the net reclassification improvement (NRI). Missing data were imputed through multiple imputation using chain equations.

Results

In all, 10’711 patients were included: 84.6% females, mean age: 54.4±13.8 years, mean disease duration: 7.9±8.2 years. In the prospective analysis (n= 6’467 to 7’829 according to the outcome), after a mean follow-up of 56 months and a mean of three visits per patient, we did not identify any difference in AUC between the cutaneous-based model and the antibody-based model for prediction of OS and disease progression. However, the NRI showed a significant improvement in prediction of OS (0.57 [0.46-0.71] vs. 0.29 [0.19-0.39]) and disease progression (0.36 [0.29-0.46] vs. 0.21 [0.14-0.28]) at 4 years using the antibody-based model. Regarding prediction of each organ involvement in longitudinal analyses, the antibody-based model showed better performance than the cutaneous-one for renal crisis (AUC: 0.719 [0.696-0.742] vs. 0.664 [0.643-0.685]), with the highest association observed with anti-RNA polymerase III (OR: 7.47 [1.63-34.24], p= 0.010). Similarly, the antibody-based model was better than the cutaneous model in predicting lung fibrosis (AUC 0.719 [0.715-724] vs. 0.653 [0.647-0.659]) and restrictive lung fibrosis (AUC 0.759 [0.749-0.766] vs. 0.711 [0.701-0.721]) which were both associated with anti-Scl70 antibodies (OR: 9.29 [8.17-10.55] and 7.92 [5.37-11.69], respectively, p<0.0001 for both). Although there was no difference in the AUC to predict digital ulcers, NRI showed an improvement using the antibody-based model (0.31 [0.29-0.33] vs. 0.24 [0.22-0.26]) with the highest association with anti-Scl70 antibodies (OR: 3.57 [2.68-4.75], p<0.0001). The two models had similar performances in assessing occurrence of intestinal involvement, heart dysfunction or elevated sPAP. Combining both antibody status and cutaneous subtype did not improve the performance of our models. In the exploratory analysis, there was no change using modified Rodnan skin score to define cutaneous form.

Conclusion

Auto-antibody status outperforms the common cutaneous subsetting to risk-stratify SSc patients in the EUSTAR cohort. This easily performed subclassification using autoantibodies specific status can be used by the clinicians to risk-stratify their patients and to adapt disease monitoring in routine practice.

Disclosure of Interests

Muriel Elhai Speakers bureau: BMS outside of the submitted work, Marouane Boubaya: None declared, Nanthara Sritharan: None declared, Alexandra Balbir-Gurman: None declared, Elise Siegert: None declared, Eric Hachulla: None declared, Jeska de Vries-Bouwstra: None declared, Gabriela Riemekasten: None declared, Jörg H.W. Distler: None declared, Douglas Veale: None declared, Edoardo Rosato: None declared, Francesco Del Galdo: None declared, Fabian A Mendoza: None declared, Daniel Furst Consultant of: Abbvie, Novartis, Pfizer, R-Pharm, Grant/research support from: Emerald, Kadmon, PICORI, Pfizer,Prometheus, Talaris, Mitsubishi, Carlos De la Puente Bujidos: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Armando Gabrielli: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Coralie Bloch-Queyrat: None declared, Yannick Allanore Consultant of: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis, Grant/research support from: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis

POS0878 ASSOCIATION OF A LOWER BODY-MASS INDEX WITH THE PRESENCE OF ILD IN SSc PATIENTS – A DERIVATION PREDICTION STUDY USING DECISION TREE-BASED ALGORITHMS

Background

Upper-gastrointestinal involvement (GI) is associated with more severe interstitial lung disease in patients with systemic sclerosis (SSc-ILD). However, there are many unexplored GI risk factors for the presence of SSc-ILD which could be potentially revealed by machine learning algorithms.

Objectives

The aim of our study was to identify GI related risk factors for the presence of SSc-ILD using machine learning algorithms based on decision trees (DT).

Methods

Data of the last follow-up visit from consecutive patients fulfilling the 2013 ACR/EULAR SSc classification criteria recorded in our local EUSTAR registry were used for this study.

The study outcome was the presence of SSc-ILD on high-resolution computed tomography.

Two sets of predictors were identified based on their potential association with GI. The first set contains the following variables available in the EUSTAR registry: esophageal symptoms (dysphagia and reflux), stomach symptoms (early satiety, vomiting), intestinal symptoms (diarrhea, bloating and constipation), malabsorption syndrome, body-mass-index (BMI) and proton pump inhibitor therapy, calcium channel blocker therapy and immunosuppressive therapy. In the second set, we replaced the first three EUSTAR variables of the first set with the scales of the UCLA Gastrointestinal Tract Questionnaire 2.0 (UCLA-GIT).

Of these two sets, the most important variable was selected using three different DT-based algorithms: (1) recursive partitioning and regression trees (RPART) –which uses trees to build decision rules, (2) random forest (RF) - an ensemble of DT built in parallel, and (3) gradient boosting machines (GBM) - an ensemble of DT built sequentially. The selected variables were eventually integrated with established predictors for presence of SSc-ILD (diffuse cutaneous subset, anti-Scl-70 positivity, male gender, forced vital capacity [FVC] and diffusion capacity of the lung for carbon monoxide-single breath [DLCO-SB]) into final prediction models for SSc-ILD presence using RPART, RF and GBM respectively. Their performance was evaluated by C-statistics. The importance of the newly detected predictor was assessed by variable importance plots (VIPs).

Results

We included in our study 334 patients. The median age was 61 [IQR: 50-69] years, 59 (17.7%) were males and 266 (79.6%) had limited cutaneous SSc. Median BMI was 23 [IQR: 21-26] kg/m2, 133 (39.8%) of the patients had SSc-ILD, median FVC% 93 [IQR: 81-105], DLCO 72.5 [56-84] and. Of the UCLA-GIT scales the highest score was for the distension/bloating with a value of 0.50 [IQR: 0-1.24]. Regarding medications, 167 (50%) patients were exposed to PPI, 39 (11.7%) to CCB and 105 (31.4%) to immunosuppressive therapy.

The BMI was deemed by all three algorithms as the most important predictor of SSc-ILD among both sets of GI related variables (Figure 1A-F). The final model, which included established risk factors for presence of ILD and the BMI, supported the importance of BMI in predicting the SSc-ILD. The VIPs obtained by GBM also ranked the BMI as the most important predictor.

Figure 1.

Tree-based algorithms revealing the importance of BMI for prediction of SSc-ILD. Panels A, B and C are variable importance plots (VIPs), which reveals the most important GI-predictor for occurrence of SSc-ILD in the EUSTAR set– the predictor with the highest relative importance is the most important predictor. Panels D, E and F are VIPs reveals the most important GI-predictor for occurrence of SSc-ILD in the UCLA-GIT set.

A lower BMI was associated with presence of SSc-ILD (C-statistics for the RPART, RF and GBM models were 0.79, 0.70 and 0.76, respectively, corresponding to a fair accuracy). As expected, also a lower FVC, and DLCO-SB, and a positivity for Scl-70 ab were associated with presence of ILD.

Conclusion

Lower BMI is a novel promising predictor for the presence of ILD, which should be confirmed in additional analyses.

Disclosure of Interests

Alexandru Garaiman: None declared, Carina Mihai Speakers bureau: MEDtalks Switzerland, Mepha, Rucsandra Dobrota Consultant of: Actelion and Boehringer-Ingelheim, Grant/research support from: Articulum Fellowship, Pfizer, Actelion, Cosimo Bruni Speakers bureau: Eli-Lilly, Actelion, Boehringer-Ingelheim, Grant/research support from: Gruppo Italiano Lotta alla Sclerodermia (GILS), European,, Scleroderma Trials and Research Group (EUSTAR), Scleroderma Clinical Trials Consortium (SCTC), AbbVie, Muriel Elhai: None declared, Suzana Jordan: None declared, Lea Stamm: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Roche, Merck Sharp & Dohme, ARXX Therapeutics, Lilly and Medscape, Consultant of: Actelion, Boehringer Ingelheim, Jansen, Roche, Merck Sharp & Dohme, ARXX Therapeutics, Lilly and Medscape, Grant/research support from: Boehringer Ingelheim, Bayer, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Medscape, Novartis, Roche, Pfizer, Roche, Sanofi, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon, Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Prometheus Biosences, Roche, Roivant, Topadur and UBC, Lilly, Pfizer, Grant/research support from: Kymera, Mitsubishi Tanabe, Mike O. Becker Speakers bureau: Mepha, MSD, Novartis, GSK, Bayer and Vifor

POS0892 IDENTIFICATION OF DEFINED MICROANGIOPATHIC CHANGES IN NAILFOLD CAPILLAROSCOPY IMAGES OF PATIENTS WITH SYSTEMIC SCLEROSIS USING A VISION TRANSFORMER MODEL – A MONOCENTRIC IMPLEMENTATION AND VALIDATION COHORT STUDY

Background

An accurate assessment of nailfold capillaroscopy (NFC) images has great importance in the diagnosis and prognosis of systemic sclerosis (SSc). To overcome some of the inherent problems with NFC image analysis (operator/observer bias, time requirements), there is an interest to automate and standardize NFC image assessment using computer vision algorithms, such as the Vision Transformer (ViT), which are based on recent advances in deep learning.

Objectives

Our aims were (1) to implement and assess the performance and the reliability of ViT in detecting changes on NFC images, and (2) to compare the performance of ViT to that of practicing rheumatologists.

Methods

For this study, we used NFC images of patients with SSc enrolled in our European Scleroderma Trials and Research group (EUSTAR) and Very Early Diagnosis of Systemic Sclerosis (VEDOSS) local registries. Concretely, we included routine NFC images (all NFC images available – digit II to V of both hands-, irrespective of any image artefacts) of patients aged ≥ 18 years with visits between 2012 and 2021, who fulfilled either the 2013 American College of Rheumatology / European League Against Rheumatism classification criteria for SSc (established disease) or the preliminary criteria for VEDOSS (mild/early disease).

ViT was trained to identify the following NFC signs of microangiopathy: enlarged capillaries (apex diameter of the capillary > 20 µm, and < 50µm), giant capillaries (> 50 µm), loss of capillaries (< 7 capillaries/mm), and microhaemorrhages. Absence of any of these signs was considered as being a “normal NFC”, while presence of any of these signs was seen as an abnormal NFC image. Its performance was evaluated in a cross-fold (k = 5) validation setting, and the gold standard was the treating physician. Area under the ROC curve (AUC) was used as indicator of the performance. Considered cut-offs for AUC were 90-100% - excellent, 80-89.9% - good, 70-79.9% - fair, 60-69.9% - poor, 50-59.9% - fail. From the first cross-fold, a randomly sampled reliability set was created which was used to compare the NFC assessment performance of four rheumatologists (three invited and trained annotators and the treating physician) with that of of ViT.

Results

We analysed 17,126 NFC images of 234 EUSTAR patients (14.6% males, 67.8% limited cutaneous SSc, median age 57 years, median disease duration 9 years) and 55 VEDOSS patients (92.7% females, median age 44 years, median time elapsed since first Raynaud’s phenomenon 5 years). ViT had fair to excellent performance in identifying the different NFC changes across all five folds (of 3443 NFC images each), with an area under the ROC curve ranging from 78.59% to 90.4% (Figure 1a).

Figure 1.

Performance of the ViT: (a) AUCs values for ViT in diagnosing the respective feature on NFC image. (b) Sensitivity / specificity trade-off across the images in the reliability set. The blue lines show the ROC curves corresponding to the ViT predictions, with ViT’s AUC, “optimal” sensitivity and specificity shown in the box. Also shown are the point performances of each of the four annotators, with performances below the blue line indicating lower performance than ViT.

In the reliability set (see Figure 1b), we observed highest performance for diagnosing giant capillaries (AUC =92.89%) followed by identification of enlarged capillaries (AUC = 91.7%). Good AUCs were seen in depicting capillary loss (AUC = 87.3%), microhemorrhages (AUC = 85.9%) and the abnormal/normal NFC classification (AUC = 84.7%). The rheumatologists had generally higher performance in assessing NFC images. However, ViT outperformed two rheumatologists with different experience in classifying capillary loss and enlarged capillaries, respectively.

Conclusion

ViT is a modern, well performing and readily available AI model to assess signs of microangiopathy on NFC images acquired during routine practice.

Disclosure of Interests

Alexandru Garaiman: None declared, Farhad Nooralahzadeh: None declared, Carina Mihai Speakers bureau: MEDtalks Switzerland, Mepha, Nikitas Gkikopoulos: None declared, Nicolas Perez Gonzalez: None declared, Mike O. Becker Speakers bureau: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Medscape, Novartis, Roche, Pfizer, Roche, Sanofi, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, Glenmark, GSK, Horizon, Inventiva, iQvia, Kymera, Lupin, Medac, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Prometheus Biosences, Roche, Roivant, Topadur and UBC, Lilly, Pfizer, Grant/research support from: Kymera, Mitsubishi Tanabe, Michael Krauthammer Speakers bureau: Oncobit, Britta Maurer Speakers bureau: Boehringer-Ingelheim, Medtalk, Pfizer, Roche, Actelion, Mepha, and MSD, Consultant of: Novartis, Boehringer Ingelheim, Janssen-Cilag, Grant/research support from: AbbVie, Protagen, Novartis Biomedical Research

POS0063 PROGRESSIVE INTERSTITIAL LUNG DISEASE IS FREQUENT ALSO IN LATE DISEASE STAGES IN SYSTEMIC SCLEROSIS PATIENTS FROM EUSTAR

Background

Short disease duration is a predictor for progressive systemic sclerosis-associated interstitial lung disease (SSc-ILD), but studies assessing ILD progression in later disease stages are lacking. To individually tailor management of ILD in SSc patients in clinical practice it is, however, of high importance to understand disease behaviour also in patients with late disease.

Objectives

Analyse ILD progression in SSc-ILD patients from the EUSTAR cohort segregated by subgroups of disease duration.

Methods

We segregated SSc-ILD patients into four categories of disease duration (≤3 years, >3- ≤7 years, >7- ≤15 years and >15 years after onset of Raynaud’s phenomenon). We assessed progressive ILD, defined as forced vital capacity (FVC) decline >10% or FVC decline ≥10% and FVC decline 5–10% and diffusing capacity of the lungs for carbon monoxide (DLCO) decline ≥15% (composite decline) over the first and second 12+/-3 months period after first registration (baseline) into EUSTAR. Clinical characteristics, pulmonary involvement, treatment at first registration and ILD progression were evaluated by descriptive statistics.

Results

In total, 2258 SSc-ILD patients were included, with 469 (20.8%) having a disease duration ≤3 years, 550 (24.4%) between >3- ≤7 years, 752 (33.3%) between >7- ≤15 years and 488 (21.6%) of >15 years (Table 1). Baseline characteristics and treatment patterns differed between the four subgroups, with more younger male patients with diffuse cutaneous SSc, anti-topoisomerase I antibody and higher Rodnan skin score having ≤3 years disease duration. Lung function with FVC and DLCO were similar between the four groups (Table 1). Notably, in the first and second 12+/-3 months periods after first registration in the EUSTAR database, there were no significant difference in FVC decline >10% or composite FVC and DLCO decline within the four subgroups. For example, patients with disease duration >7- ≤15 years and >15 years frequently showed disease progression of FVC >10%: 41/347 (11.8%) and 32/228 (14%) compared to 38/244 (15.6%) and 33/273 (15.6%) for disease duration ≤3 years and >3- ≤7 years (P=0.529), respectively (Figure 1).

Table 1.

Demographics and baseline clinical characteristics of EUSTAR patients

Disease duration≤ years(n=460)>3- ≤7 years(n=550)>7- ≤15 years(n=752)>15 years(n=488)p-valueAge, years (SD)55 (13.5)55 (14.1)57 (13.1)61 (11.5)<0.001Male, n (%)123 (26.2)115 (20.9)112 (14.9)38 (7.8)<0.001DcSSc, n (%)228 (56.4)262 (45.8)311 (45.4)163 (31.2)<0.001ATA, n (%)236 (53.4)293 (55.9)374 (52.8)218 (48.0)0.099mRSS, mean (SD)12.3(10.1)10.4 (8.3)9.4 (8.1)8.7 (7.7)<0.001GERD, n/N (%)273 (58.7)353 (64.4)482 (64.4)344 (71.2)0.001ESR, mean (SD)26.9(21.7)24.2 (19.5)26.2 (19.9)28.3 (21.2)0.022MMF, n/N (%)33 (16.6)43 (25.2)37 (20.4)14 (9.3)0.002MTX, n/N (%)19 (10)17 (10.1)19 (10.6)8 (5.2)0.296Any IS, n/N (%)81 (38.6)89 (47.1)82 (40.8)46 (28.7)0.006FVC % pred, mean (SD)86 (20.9)87 (21.6)86 (21.4)87 (22.8)0.770DLCO % pred, mean (SD)58 (19.3)59 (19.3)59 (19.9)58 (19.7)0.405NYHA class 3&4, n (%)84 (18.6)78 (14.6)125 (17.5)22.6 (7.0)0.090Figure 1.

FVC decline >10% and composite FVC and DLCO decline in the first and second 12+/-3 months within the four subgroups segregated by disease duration

Conclusion

It was long believed that ILD burned out in late disease stages. In our analysis of ILD progression by four disease duration categories, we showed that ILD frequently progressed also in late disease stages. This has important implications for clinical practise, as SSc patients need to be regularly monitored for ILD progression independent of disease duration.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Cathrine Brunborg: None declared, Paolo Airò Speakers bureau: Bristol-Myers-Squibb, Boehringer Ingelheim, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Jannsen, CSL Behring, Lidia P. Ananyeva Speakers bureau: Boehringer Ingelheim, Grant/research support from: Boehringer Ingelheim, László Czirják Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Roche, Lilly, Grant/research support from: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Serena Guiducci: None declared, Eric Hachulla Speakers bureau: GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Consultant of: CSL Behring, GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Grant/research support from: CSL Behring, Boehringer Ingelheim, GSK, Roche-Chugai, Sanofi Genzyme, Mengtao Li: None declared, Carina Mihai Speakers bureau: MEDtalks Switzerland, Mepha, Grant/research support from: Roche, Boehringer Ingelheim, Janssen, Gabriela Riemekasten Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Petros Sfikakis Consultant of: Boehringer Ingelheim, Gabriele Valentini Consultant of: Boehringer Ingelheim, Grant/research support from: Sanofi/BMS, Otylia Kowal-Bielecka Speakers bureau: Boehringer Ingelheim, Novartis, Pfizer, Gilead Sciences, Janssen-Cilag, MEDAC, MSD, Abbvie, Sandoz, Consultant of: Boehringer Ingelheim, Health Care system Navigator, CSL Behring, MSD, Novartis, Grant/research support from: CSL Behring, Boehringer Ingelheim, Abbvie, Roche, MEDAC, Yannick Allanore Speakers bureau: Boehringer, Abbvie, Consultant of: Boehringer, Bayer, Astra-Zeneca, Prometheus, Sanofi, Genentech/Roche, Boehringer, Grant/research support from: Alpine Immunosciences, OSE Immunotherapeutics, Medsenic, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim

POS0426 BRD3 REGULATES THE INFLAMMATORY AND STRESS RESPONSE IN RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLASTS

Background

Small molecule inhibitors targeting members of the bromodomain and extra-terminal (BET) protein family (BRD2, BRD3, BRD4) have anti-inflammatory properties in rheumatoid arthritis (RA). BET proteins are readers of acetylated histone side chains and activators of transcription. BRD3 is an understudied member of BET proteins.

Objectives

To analyse individual functions of BET proteins and mechanisms underlying BET inhibition in RA synovial fibroblasts (SF).

Methods

The expression of BRD2, BRD3, and BRD4 was silenced by lenti-viral transduction followed by TNF stimulation (10 ng/µl, 24h). Silencing was confirmed by Western blotting. Transcriptomes were determined by RNA-seq (Illumina NovaSeq 6000, n=3). Pathway enrichment analysis for KEGG and Reactome databases was conducted with significantly affected genes (± fold change > 1.5, FDR < 0.05). SF were treated with I-BET (1 µM) and TNF (10 ng/µl, 24h). Autophagy was evaluated by Western blotting using the conversion of LC3B as a marker (n=9). I-BET-induced global changes on post-translational histone modifications were analysed by mass spectrometry (Mod Spec, Active Motif; n=2; 120h protocol) and Western blotting (H3K27ac, H3K18ac, total acH3; n=7; 24h and 120h protocol). For this purpose, SF were stimulated with I-BET (1 µM) for 24h, and either co-stimulated with TNF (24h protocol), or washed with PBS, followed by a 24h stimulation with TNF 120h after the I-BET treatment (120h protocol).

Results

Silencing of BRD2 and BRD4 in SF was, in contrast to silencing of BRD3, associated with high levels of cell death, and therefore not analyzed further. We detected 257 and 324 differentially expressed genes (DEG) that were affected by BRD3 silencing in unstimulated and TNF-stimulated SF, respectively. 105 DEG overlapped between the two groups. DEG were enriched in inflammatory pathways such as “TNF signaling pathway”, “rheumatoid arthritis”, “Toll-like receptor cascades”, “MAPK signaling pathway”, “IL-17 signaling pathway” and “signaling by interleukins”. Furthermore, pathway enrichment analysis suggested a role for BRD3 in different stress-associated pathways, including “DNA repair”, “chaperone mediated autophagy”, “cellular responses to stress”, and “autophagy”. In line with the pathway enrichment analysis, I-BET induced levels of LC3B-II in unstimulated (4.3 fold, p=0.07) and TNF-stimulated (2.9 fold, p=0.07) SF, indicating a role of BET proteins in the regulation of autophagy. To further study the mechanisms underlying I-BET-mediated suppression of gene expression, we analyzed potential effects of I-BET on histone modifications. Mod Spec analysis indicated that I-BET induced profound changes in chromatin modifications, with a global reduction of acetylation on different histone side chains. We confirmed some of these differences in independent samples. I-BET treatment reduced mean TNF-induced levels of total acH3 by 25.2% (120h; p=0.0303), of H3K18ac by 35.3% (24h; p=0.0288) and by 29.3% (120h; p=0.0373) and of H3K27ac by 41.7% (120h; p=0.0587).

Conclusion

BRD3 acts as an upstream regulatory factor that integrates the response to inflammatory stimuli and stress conditions in SF. Our data suggest that BET inhibitors do not only prevent the reading of acetylated histone side chains, but also directly affect the chromatin structure, in particular by downregulating global levels of histone acetylation.

Disclosure of Interests

Malgorzata Maciukiewicz: None declared, Larissa Moser: None declared, Monika Krosel: None declared, Tanja Seifritz: None declared, Matija Tomsic: None declared, Britta Maurer Speakers bureau: Boehringer-Ingelheim, Consultant of: Novartis, Boehringer Ingelheim, Janssen-Cilag, Grant/research support from: AbbVie, Protagen, Novartis Biomedical Research, Oliver Distler Consultant of: Abbvie, Caroline Ospelt: None declared, Kerstin Klein Grant/research support from: Novartis Foundation for biomedical research (2019)

AB1236 CLINICAL CHARACTERISTICS OF JUVENILE ONSET SYSTEMIC SCLEROSIS PATIENTS FROM THE JUVENILE SCLERODERMA INCEPTION COHORT COMPARED TO ADULT AGE JUVENILE-ONSET PATIENTS FROM EUSTAR. ARE THESE DIFFERENCES SUGGESTING RISK FOR MORTALITY?

Background

Juvenile systemic sclerosis (jSSc) is an orphan autoimmune disease with a prevalence of 3 in 1 000 000 children. Information on long-term development of organ involvement and clinical characteristics of jSSc patients in adulthood are lacking. It was believed that patients in adult cohorts may represent a survival biased population.

Objectives

To assess differences in clinical characteristics of jSSc-onset patients from the pediatric age group, with a mean disease duration of 3 years, compared to the adult age jSSc-onset group, with a mean disease duration of 18.5 years.

Methods

We extracted clinical data at time of inclusion into the cohorts from the Juvenile Scleroderma Inception Cohort (jSScC) and data from juvenile-onset adult SSc patients from the European Trials and Research Group (EUSTAR) cohort. We compared the clinical characteristics of the patients by descriptive statistics.

Results

We extracted data of 187 jSSc patients from the jSScC and 236 patients from EUSTAR. The mean age at time of assessment was 13.4 years old in the jSScC and 32.4 years old in EUSTAR. The mean disease duration since first non-Raynaud was 3.0 years in jSScC and 18.5 years in the EUSTAR (Table 1).

We found significant differences between the cohorts. There were more female patients in EUSTAR (87.7% versus 80.2%, p=0.04). More patients had diffuse subtype in jSScC (72.2% versus 40%, p<0.001). The modified Rodnan skin score (mRSS) was significantly higher in jSScC (14.2 versus 12.1, p=0.02). Active digital ulceration occurred more often in EUSTAR (26.6%, versus 17.8% p=0.01), but history of active ulceration was more frequent in jSScC (54.1% versus 43%, p<0.001). Mean DLCO was lower in jSScC (75.4 versus 86.3, p<0.001). Intestinal involvement was significantly more common in jSSc (33.2% versus 23.8%, p=0.04). Esophageal involvement was more common in EUSTAR (63.7% versus 33.7%, p<0.001). (Table 1).

Table 1.

Clinical characteristics of juvenile onset SSc patients at time point of the inclusion into the juvenile scleroderma inception (jSScC) cohort and in the adult EUSTAR- cohort

jSScCEUSTAR CohortP valueNumber of patients1872360.04Age in years, mean (SD)13.4 (3.6)32.4 (15.4)Female patients, n (%)150 (80.2%)207 (87.7%)jSSC Subtype, n (%)diffuse135 (72.2%)87 (38.1%)<0.001limited52 (27.8%)121 (53.3%)Age at Raynaud onset in years, mean (SD)10.0 (3.9)13.7 (9.1)Age at non-Raynaud onset in years, mean (SD)10.3 (3.9)11.7 (3.7)Duration since first Raynaud symptoms in years, mean (SD)3.4 (2.7)20.6 (15.9)Duration since first non-Raynaud symptoms in years, mean (SD)3.0 (2.7)18.5 (15.6)Raynaud´s, n (%)170 (90.9%)222 (94.9%)ANA positive, n (%)166 (91.7%)210 (92.9%)0.99Anti-Scl 70 positive, n (%)62 (34.4%)73 (33.3%)0.68Modified Rodnan Skin Score, mean (SD)5%Data missingModified Rodnan Skin Score, mean (SD)14.2 (11.7)12.1 (14.5)0.02Digital ulceration, n (%)At the time of inclusion33 (17.8)21 (26.6%)0.01In the past history100 (54.1%)34 (43%)<0.001Telangiectasia62 (37.4%)42 (53.2%)0.04FVC, mean (SD)84.1 (18.6)84 (22.4)0.96DLCO, mean (SD)75.4 (19.2)86.3 (19.9)<0.001Arterial hypertension, n (%)10 (5.4%)20 (8.5%)0.26Renal crisis, n (%)03 (1.3%)0.26Esophageal involvement, n (%)63 (33.7%)149 (63.7%)<0.001Intestinal involvement, n (%)62 (33.2%)56 (23.8%)0.04Articular involvement, n (%)34 (18.3%)27 (11.6%)0.06Muscular involvement, n (%)31 (19.3%)46 (19.8%)0.45

Conclusion

Patients with jSSc-onset who are currently adult age (defined as >18 years of age) are less frequently male and from the diffuse subset, have lower mRSS, less digital ulcers and intestinal involvement. This might represent a combination of both survival bias and/or be explained by the longer observation time with less active disease (i.e. natural progression decreased mRSS over time). Further long-term observational studies with jSSc patients are required to address this issue.

Disclosure of Interests

None declared

POS0900 SYSTEMIC PHARMACOLOGICAL TREATMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers (DU) are common in systemic sclerosis (SSc) and associated with reduced survival, high morbidity and poor quality of life. Recommendations have previously been proposed for DU management yet there remains significant unmet patient need. Therefore the World Scleroderma Foundation DU Working Group intends to develop practical evidence based recommendations for DU management.

Objectives

To summarise data on efficacy and safety of systemic treatments for SSc DU.

Methods

A systematic literature review to May 2021 was performed. PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, Emcare (OVID) and Academic Search Premier databases were searched for original studies on adult patients with SSc DU treated with systemic pharmacological treatment. Based on the PICO framework, eligibility criteria were defined and references were independently screened by two reviewers. Reviewers independently assessed the full text of eligible articles. Owing to interstudy heterogeneity narrative summaries were used to present data.

Results

The search strategy identified 1271 references of which 45 eligible articles were included. Seventeen studies were randomised placebo controlled trials (RCT) pertaining to PDE5 antagonists (PDE5i) (n=3), endothelin receptor antagonists (ERA) (n=3), prostanoids (n=7), antiplatelet agents (n=1) and other (n=3) (Table 1). No head to head RCT was retrieved. All other studies were observational studies (OBS). Studies were highly heterogeneous with application of differing definition of DU, variable study eligibility criteria, clinical endpoints and follow up periods. This limited the calculation of effect size and comparison across studies.

Table 1.

Characteristics of placebo controlled randomised controlled trials

Author YearInterventionnFollow upOutcomeFavours interventionHachulla 2016Sildenafil8312 weeksTime to DU healing-Andrigueti 2017Sildenafil4112 weeksDU healing+Shenoy 2010Tadalafil246 weeksNew DU+Khanna 2016Macitentan55416 weeksNew DU-Matucci-Cerinic 2011Bosentan18832 weeksNew DU Time to healing of DU+-Korn 2004Bosentan12212 weeksNew DU+Kawald 2008IV iloprost5012 monthsDU healing-Wigley 1992IV iloprost3510 weeksDU healing+Wigley 1994IV iloprost739 weeks50% reduction in DU score-Seibold 2017Treprostinil14820 weeksNet DU burden-Vayssairat 1999Beraprost10725 weeks% patients with new DU-Denton 2017Selexipag7412 weeksNumber of new DU DU healing-Lau 1993Cicaprost334 weeksNumber of DU-Abou-Raya 2008Atorvastatin844 monthsNumber of DU+Au 2010Cyclophosphamide15812 monthsNumber of patients with DU-Beckett 1984Dipyridamole / aspirin412 yearsChange in general SSc-Nagaraja 2019Riociguat1732 weeksNet DU burden-

+ significantly superior to comparator

- non significantly different from comparator

DU: digital ulcers IV: intravenous SSc: systemic sclerosis

Several RCT found improved DU healing with treatment: two with PDE5i, one with iloprost and one showed improved DU healing and prevention with atorvastatin. Two RCT demonstrated effective prevention of new DU with bosentan. OBS studies with a total of 621 patients showed variable improvements in the healing of DU with CCB, PDE5i, ERA, statins, N-acetylcysteine, prostanoids and ketanserin and prevention of new DU with ERA.

Regarding safety, all treatments were generally tolerated with few serious adverse events. Treatment was ceased in 6.25-17.5% of patients in RCT due to treatment related side effects.

Conclusion

Despite several studies assessing the efficacy and safety of systemic pharmacological treatment of SSc DU, it is not possible to draw solid conclusions due to study heterogeneity. Small RCT have shown treatment benefit with PDE5i, iloprost and atorvastatin. Large studies demonstrated effective prevention of new DU with bosentan. Our results highlight the urgent need for improved clinical trial design to generate more robust evidence and novel therapies to guide the management SSc DU.

Acknowledgements

This work was supported by the World Scleroderma Foundation.

Disclosure of Interests

Nancy Maltez: None declared, Laura Ross: None declared, Michael Hughes Speakers bureau: Actelion Pharmaceuticals, Eli Lilly and Pfizer outside of the submitted work., Jan Schoones: None declared, Murray Baron: None declared, Lorinda Chung Consultant of: Eicos, Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: Actelion Pharmaceuticals, Boehringer Ingelheim, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Grant/research support from: Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143), Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Consultant of: Eicos Sciences Inc, Janssen, Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speaker fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and consultancy fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0880 CHARACTERISTICS AND DISEASE COURSE OF UNTREATED PATIENTS WITH INTERSTITIAL LUNG DISEASE ASSOCIATED WITH SYSTEMIC SCLEROSIS

Background

Interstitial lung disease (ILD) is the leading cause of death in systemic sclerosis (SSc). European consensus guidelines consider that some patients with mild disease might not need pharmacological treatment (1). Up to now, the disease characteristics and the disease course of non-treated SSc-ILD patients remain unknown.

Objectives

To describe disease characteristics and the disease course of non-treated SSc patients with ILD.

Methods

We included patients from our local EUSTAR center registered since 2008, who had a diagnosis of ILD on high-resolution computed tomography (HRCT) and available data on pulmonary function tests and treatment. Longitudinal study included patients with at least one follow-up visit. Patients were classified as treated if they received a potential ILD modifying drug (immunosuppressive therapy or nintedanib). Treated and untreated patients were compared at baseline. Progression in the untreated group was defined as (i) forced vital capacity (FVC) decline from baseline of ≥10% or (ii) an FVC decline of 5-9% in association with a decline in diffusing capacity for carbon monoxide (DLCO) of ≥15%, or (iii) start of a ILD modifying treatment during follow-up. In the untreated group, patients who progressed at any time were compared with patients with stable disease during follow-up. Multivariable logistic regression was performed to identify (i) factors associated with non-prescription of a treatment in ILD patients at baseline and (ii) factors associated with progression in the untreated patients. Covariates were selected according to clinical experience and literature evidence.

Results

Among 496 patients included in our cohort, 209 (42%) patients had ILD on baseline HRCT: 48/209 (23%) were males, median disease duration 8 [IQR: 4-12] years, 67/209 (32%) of diffuse cutaneous subset and 86/209 (41%) had anti-Scl70 antibodies.

Among them, 142/209 (68%) did not receive any potentially ILD modifying treatments at baseline. Untreated patients were older (59 vs. 54 years), had a longer disease duration, were less frequently smokers, had more frequently anticentromere antibodies and lower levels of CRP. They had more frequently a limited extent (<20%) of lung fibrosis on HRCT, higher FVC (97.02 (±19.76) % vs. 78.29 (±19.23) %) and DLCO (72.10 (±18.97) % vs. 57.57 (±20.81) %), better performances in the 6 minute walking test and were less frequently treated with low dose of glucocorticoids.

In multivariable logistic regression, older age (OR: 1.04 [1.01-1.08], p=0.021), a less extensive disease on HRCT (OR: 0.29 [0.09-0.90], p=0.037) and less frequent prescription of glucocorticoids (OR: 0.036 [0.12-0.92], p=0.037) were independently associated with absence of ILD modifying treatment prescription in our cohort.

From the 142 untreated patients, 96 were followed-up for 64 [39-96] months. Of these, 56 (58%) patients showed progression of ILD, of whom 43 progressed by lung function parameters. Of these 56 patients, 31 (56%) progressed in the first 18 months. Diffuse cutaneous subtype (OR: 5.26 [1.26-27.62], p=0.031), shorter disease duration (OR: 0.95 [0.90-0.99], p=0.035) and oesophageal symptoms (reflux, dysphagia) (OR: 3.51 [1.12-12.18], p=0.036) at baseline were independent predictors of progression during follow-up in untreated patients.

Conclusion

A considerable number of SSc patients with ILD are not treated in clinical practice, in particular patients with limited cutaneous SSc, older age and an overall less extensive ILD. However, during a follow-up of 5 years, contrary to the common belief, about 60% of the untreated patients showed ILD-progression. The diffuse cutaneous subtype, shorter disease duration and oesophageal symptoms at baseline characterized these patients. With the development of effective and safe therapies for SSc-ILD, our results support a change in practice for selecting patients for treatment.

References

[1]Hoffmann-Vold A-M, et al. The Lancet Rheumatology. 2020;2(2):e71-e83.

Disclosure of Interests

Moritz Scheidegger: None declared, Alexandru Garaiman: None declared, Carina Mihai Speakers bureau: Boehringer-Ingelheim, MED Talks Switzerland, Consultant of: Boehringer-Ingelheim (advisory board), Janssen (advisory board), Mike O. Becker Speakers bureau: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Consultant of: Mepha, MSD, Novartis, GSK, Bayer and Vifor (advisory board fees), Rucsandra Dobrota Consultant of: Boehringer-Ingelheim (Advisory Board), Cosimo Bruni Speakers bureau: Eli-Lilly2018-2021, Actelion2019, Boehringer-Ingelheim2020-2021, Grant/research support from: AbbVie (educational grant 2021), Suzana Jordan: None declared, Håvard Fretheim Speakers bureau: Personal fees form Bayer and non-financial support from GSK and Actelion, outside the submitted work., Øyvind Midtvedt: None declared, Hilde Jenssen Bjørkekjær: None declared, Imon Barua: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Muriel Elhai Speakers bureau: Speaker fees: BMS outside the submitted work

OP0003 DOES IMMUNOSUPPRESSIVE THERAPY IMPROVE GASTROINTESTINAL SYMPTOMS IN PATIENTS WITH SYSTEMIC SCLEROSIS?

Background

The gastrointestinal (GI) tract is frequently affected in systemic sclerosis (SSc), leading to considerable morbidity and even mortality. While important progress has been made in the last years regarding treatment of SSc, there is no disease-modifying treatment available for SSc-related GI involvement.

Objectives

We aimed to identify, in an observational cohort study of real-life patients with SSc, an association between immunosuppressive therapy and the severity of GI symptoms, measured by the University of California at Los Angeles / Scleroderma Clinical Trial Consortium Gastro-Intestinal Tract instrument 2.0 (UCLA GIT 2.0).

Methods

We selected patients from our EUSTAR centre who met the 2013 ACR/EULAR classification criteria for SSc and had at least two visits with completed UCLA GIT 2.0 questionnaires, with an interval of 12±3 months between visits. We defined the first visit with a completed UCLA GIT 2.0 questionnaire as baseline visit. Immunosuppressive therapy was defined as exposure for at least 6 months between the two visits to at least one of the following drugs, regardless of indication: mycophenolate mofetil (MMF), cyclophosphamide, methotrexate, azathioprine, leflunomide, glucocorticoids (>10mg/d prednisone-equivalent), rituximab, tocilizumab, and abatacept. The study outcome was the UCLA GIT 2.0 score at the follow-up visit. We performed multivariable linear regression with this outcome as dependent variable and immunosuppressive therapy during follow-up, immunosuppressive therapy before baseline, baseline UCLA GIT 2.0 score and several baseline parameters selected by clinical judgment as potentially influencing GI symptoms, as independent variables. Multiple imputation was implemented to handle missing values.

Results

We included 209 patients. Baseline characteristics were: 82.3% female, median (IQR) age 59.0 (48.6, 68.2) years, median disease duration 6.0 (2.7, 12.5) years, 40 (19.1%) diffuse cutaneous SSc, median baseline UCLA GIT 2.0 score 0.19 (0.06, 0.43). Of these, 71 patients were exposed to immunosuppressive therapy during the observation period: 27/71 methotrexate, 1/71 cyclophosphamide, 17/71 MMF, 3/71 leflunomide, 3/71 azathioprine, 6/71 glucocorticoids >10mg/d, 16/34 rituximab, 18/34 tocilizumab. Patients on immunosuppressive therapy during the observation period had, compared to patients without such treatment, overall more severe SSc, higher prevalence of treatment with proton pump inhibitors, similar UCLA GIT 2.0 scores at baseline and at follow up and tendentially less severe GI symptoms at baseline and follow-up by medical history. In multivariable linear regression, immunosuppressive therapy, lower body mass index, longer disease duration and lower baseline UCLA GIT 2.0 score were significantly associated with lower (better) UCLA GIT 2.0 scores at follow-up (Table 1).

Table 1.Predictors of UCLA GIT 2.0 score at follow-upEstimates95% CIpAge0.002-0.001 – 0.0060.136Sex [male]-0.056-0.172 – 0.0610.347Disease duration-0.005-0.009 – -0.0000.030Body mass index0.0140.002 – 0.0250.017UCLA GIT 2.0 total score baseline0.6900.571 – 0.809<0.001Immunosuppressive therapy during observation period-0.119-0.228 – -0.0100.032Immunosuppressive therapy before baseline0.080-0.032 – 0.1920.160Modified Rodnan Skin Score-0.001-0.008 – 0.0070.860Forced vital capacity-0.001-0.004 – 0.0010.302Erythrocyte sedimentation rate0.003-0.001 – 0.0060.116Proton pump inhibitors-0.034-0.120 – 0.0520.435(Intercept)-0.120-0.531 – 0.2910.566

Baseline factors associated with the total UCLA GIT 2.0 score at the end of the observation period. Multiple linear regression model with imputation for missing variables. N=209 patients

Conclusion

Immunosuppressive treatment was associated with lower UCLA GIT 2.0 scores, which suggests potential effects of immunosuppressants on GI manifestations in patients with SSc. These results need verification in additional studies and randomised controlled clinical trials.

References

[1]Khanna D et al. Arthritis Rheum, 2009; 61: 1257-63.

Disclosure of Interests

Lea Stamm: None declared, Alexandru Garaiman: None declared, Norina Zampatti: None declared, Mike O. Becker Speakers bureau: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Consultant of: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Grant/research support from: Mepha, MSD, Novartis, GSK, Bayer and Vifor, Cosimo Bruni Speakers bureau: Actelion, Eli-Lilly, Boehringer-Ingelheim, Grant/research support from: Abbvie, EUSTAR, Gruppo Italiano Lotta alla Sclerodermia (GILS), SCTC, Rucsandra Dobrota Consultant of: Boehringer-Ingelheim, Grant/research support from: Iten-Kohaut Foundation, Muriel Elhai: None declared, Sherif Ismail Grant/research support from: EULAR scientific training grant for young fellows 2021, Suzana Jordan: None declared, Aurora Tatu: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Carina Mihai Speakers bureau: Boehringer-Ingelheim, Mepha, MED Talks Switzerland, Consultant of: Boehringer-Ingelheim, Janssen, Grant/research support from: Boehringer-Ingelheim, Janssen, Roche.

OP0212-HPR PATIENT ASSESSMENT CHRONIC ILLNESS CARE (PACIC) AND ITS ASSOCIATIONS WITH QUALITY OF LIFE AMONG SWISS PATIENTS WITH SYSTEMIC SCLEROSIS – A MIXED METHODS STUDY

Background

Variable disease presentation and symptom burden in patients living with systemic sclerosis (SSc) require a chronic care approach including competent, coordinated, multidisciplinary collaboration as well as self-management support targeting individual patient needs. The Chronic Care Model (CCM) is a longstanding and widely adopted model guiding chronic illness management.1 Little is known about how CCM elements are implemented in SSc care or how patients’ care experiences relate to health-related quality of life (HRQoL).

Objectives

First, to describe current SSc care in Switzerland according to the CCM from the patient perspective and examine relationships with HRQoL. Second, to explain these results by patients’ illness and care experiences.

Methods

We employed an explanatory sequential mixed methods design (Figure 1). First, we conducted a cross-sectional quantitative survey (n=101 Swiss patients) using the Patient Assessment of Chronic Illness Care (PACIC-20)2 and Systemic Sclerosis Quality of Life (SScQoL)3 questionnaires. Because PACIC has not been used in the context of SSc, we used the Mokken model to test the construct validity of the PACIC scale and its subscales. After excluding five problematic items, H coefficients were ‘strong’ for the subscales and the global scale (0.52) suggesting a robust unidimensional scale.

Figure 1.

Schematic of the explanatory, sequential mixed methods design

Next, we used data from individual patient interviews (n=4) and one patient focus group (n=4) to further explore care experiences of people living with SSc with a focus on the PACIC dimensions.

Results

The mean overall PACIC-15 score was 3.0 / 5.0 (95% CI: 2.8–3.2, n= 100), indicating care was ‘never’ to ‘generally not’ aligned with the CCM. Lowest subscale scores related to ‘goal setting/tailoring’ (mean = 2.5, 95% CI: 2.2–2.7) and ‘problem solving/contextual counselling’ (mean = 2.9, 95% CI: 2.7–3.2) (Table 1). No significant associations were identified between the mean PACIC-15 and SScQoL scores.

Table 1.

Summary of scores (n=101) for the 15-item PACIC scale (adapted version of the original 20-item scale)

PACIC mean scores (95% CI)PACIC 15-item mean score3.0 (2.8–3.2)1: Patient activation(mean of items 1–3)3.4 (3.1–3.6)2: Delivery system design/ Decision Support(items 4–6)3.2 (3.0–3.4)3: Goal setting/ Tailoring(items 7–9)2.5 (2.2–2.7)4: Problem solving/ Contextual Counselling(items 12–15)2.9 (2.7–3.2)5: Follow-up/ Coordination(items 19–20)3.3 (3.0–3.5)

Note: CI=Confidence interval; PACIC=Patient Assessment of Chronic Illness Care

Interviews revealed patients frequently encounter major shortcomings in care including experiencing organized care with limited participation, not knowing which strategies are effective or harmful and feeling left alone with disease and psychosocial consequences. Patients often responded to challenges by dealing with the illness in tailored measure, taking over complex coordination of care and relying on an accessible and trustworthy team.

Conclusion

The low PACIC mean overall score is comparable to findings in patients with common chronic diseases. Key elements of the CCM have yet to be systematically implemented in Swiss SSc management. Identified gaps in care related to lack of shared decision-making, goal-setting and individual counselling –aspects that are essential for supporting patient self-management skills. Furthermore, there appears to be a lack of complex care coordination tailored to individual patient needs.

References

[1]Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract 1998;1(1):2-4.

[2]Glasgow RE, Wagner EH, Schaefer J, et al. Development and validation of the Patient Assessment of Chronic Illness Care (PACIC). Med Care 2005;43(5):436-44.

[3]Ndosi M, Alcacer-Pitarch B, Allanore Y, et al. Common measure of quality of life for people with systemic sclerosis across seven European countries: a cross-sectional study. Ann Rheum Dis 2018;77(7):1032-38.

Acknowledgements

We wish to thank the participating patients, the Swiss Scleroderma patient association, and the focus group participants for their generosity and collaboration.

Disclosure of Interests

Agnes Kocher Consultant of: Pfizer, Grant/research support from: Boehringer Ingelheim, Swiss Nursing Science Foundation, Swiss League Against Rheumatism, University of Basel, Michael Simon: None declared, Andrew A. Dwyer Grant/research support from: Boston College, U.S. National Institutes of Health (U.S.A.), Catherine Blatter: None declared, Jasmina Bogdanovic: None declared, Patrizia Künzler-Heule: None declared, Peter Villiger: None declared, Diana Dan: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Ulrich Walker: None declared, Dunja Nicca: None declared

OP0158 COHORT ENRICHMENT STRATEGIES FOR PROGRESSIVE INTERSTITIAL LUNG DISEASE IN SYSTEMIC SCLEROSIS FROM EUSTAR

Background

Enrichment strategies from clinical trials for progressive systemic sclerosis-associated interstitial lung disease (SSc-ILD) have been partly successful but have not been tested in a real life cohort.

Objectives

Analyse the efficacy, representativeness and feasibility of enrichment strategies in SSc-ILD patients from the EUSTAR cohort.

Methods

We applied the inclusion criteria of major recent SSc-ILD trials (focuSSced, SLS II and SENSCIS) in SSc-ILD patients and assessed progressive ILD, defined as absolute change in forced vital capacity (FVC) and as significant progression (FVC decline >10%) over time. Data were compared to all patients and patients not fulfilling any inclusion criteria.

Results

In total, 2258 SSc-ILD patients were included, with 31.2% meeting SENSCIS, 5.8% SLS II, 1.6% focuSSced criteria and 1529 (67.7%) not meeting any criteria (Table 1). In the first 12+/-3 months, a slow FVC% decline of –0.1% was seen in the total, unselected cohort and in patients fulfilling SENSCIS criteria. Patients fulfilling criteria from focuSSced showed a strong FVC decline of –3.7%. Notably, patients enriched for SLS II criteria showed FVC improvement of +2.3% (Figure 1). Similarly, compared to the total unselected cohort, the number of significant progressive events was numerically higher in patients fulfilling focuSSced criteria, the same for SENSCIS criteria and even slightly lower for patients fulfilling the SLS2 criteria.

Table 1.

Demographics and baseline clinical characteristics of EUSTAR patients

Not fulfilling any criteria (n=1529)focuSSced (n=36)SLS II (n=132)SENSCIS (n=704)Age, years (SD)58.4 (2.9)51.5 (12.2)†51.2 (12.7) †54.2 (13.8) †Male, n (%)231 (15.1)7 (19)35 (27)**156 (21)*Disease duration, months (SD)156.3 (99.4)16.1 (13.9)†40.7 (25.2) †39.4 (23.9) †DcSSc, n (%)597 (43.8)36 (100) †85 (65) †35 (52) †ATA, n (%)735 (51.1)24 (67)*85 (69) †370 (56)mRSS, mean (SD)9.5 (8.3)21 (6.5)*13 (9.6)*11 (9.2)GERD, n (%)1002 (65.9)25 (69)92 (70)430 (62)ESR, mean (SD)27 (20.5)43.1 (23) †29.6 (19.6) †24.7 (20.7)MMF, n (%)75 (16.5)0 (0) †0 (0) †52 (22) †MTX, n (%)42 (9.2)0 (0) †2 (5)20 (9)FVC % predicted, mean (SD)85.7 (22.5)88 (13.6)*66 (9.1) †88 (19.8)DLCO% predicted, mean (SD)58.9 (21.5)61 (12.7)49(14.6)†59 (14.2)NYHA class, n (%)3261 (17.8)6 (19)28 (21)72 (10)*440 (2.7)0 (0)3 (2)4 (1)*

*P-value: 0.001–0.05; †P<0.001, between focuSSced, SENSCIS or SLS compared with not fulfilling any study criteria.

In the second 12 months period, SENSCIS enriched patients had a further absolute FVC% decline as described for the total cohort. In contrast, patients fulfilling the focuSSced and SLS II inclusion criteria showed numerical improvement of lung function in the second period (Figure 1). There were no significant associations of enrichment criteria and ILD progression in the second period.

Over the mean observation period of 2.3 years, patients not fulfilling any inclusion criteria showed the same FVC decline of –0.9 (12.1) as observed for the total cohort (–0.9% (12.6)). There were numerical differences in FVC changes in the enriched patient cohorts, varying from –2.8% FVC decline in patients fulfilling the focuSSced criteria to +3.4% FVC improvement with SLS II criteria.

Conclusion

Application of enrichment criteria from previous clinical trials showed enrichment for progression with variable success but led to selected patient populations reducing feasibility of recruitment. These findings are important for future clinical trial design and interpretation of the results of published trials.

Acknowledgements

We thank all EUSTAR collaborators.

Disclosure of Interests

Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Cathrine Brunborg: None declared, Paolo Airò Speakers bureau: Bristol-Myers-Squibb, Boehringer Ingelheim, Consultant of: Bristol-Myers-Squibb, Grant/research support from: Bristol-Myers-Squibb, Roche, Jannsen, CSL Behring, Lidia P. Ananyeva Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, László Czirják Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Roche, Lilly, Grant/research support from: Boehringer Ingelheim, Actelion (now GSK), MSD, Novartis, Pfizer, Serena Guiducci: None declared, Eric Hachulla Speakers bureau: GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Consultant of: CSL Behring, GSK, Roche-Chugai, Johnson & Johnson, Boehringer Ingelheim, Grant/research support from: CSL Behring, Boehringer Ingelheim, GSK, Roche-Chugai, Sanofi Genzyme, Mengtao Li: None declared, Carina Mihai Speakers bureau: MEDtalks Switzerland, Mepha, Grant/research support from: Roche, Boehringer Ingelheim, Janssen, Gabriela Riemekasten Speakers bureau: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Petros Sfikakis Consultant of: Boehringer Ingelheim, Gabriele Valentini Consultant of: Boehringer Ingelheim, Sanofi, Grant/research support from: BMS, Otylia Kowal-Bielecka Speakers bureau: Boehringer Ingelheim, Novartis, Pfizer, Gilead Sciences, Janssen-Cilag, MEDAC, MSD, Abbvie, Sandoz, Consultant of: Boehringer Ingelheim, Health Care system Navigator, CSL Behring, MSD, Novartis, Grant/research support from: CSL Behring, Boehringer Ingelheim, Abbvie, Roche, MEDAC, Yannick Allanore Speakers bureau: Boehringer, Abbvie, Consultant of: Boehringer, Bayer, Astra-Zeneca, Prometheus, Sanofi, Genentech/Roche, Boehringer, Grant/research support from: Alpine Immunosciences, OSE Immunotherapeutics, Medsenic, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim

OP0092 DECIPHERING THE SYNOVIAL TISSUE AND FIBROBLAST SUBSETS IN SYSTEMIC SCLEROSIS

Background

Articular involvement is underestimated in systemic sclerosis (SSc), but represents a major cause of disability and is a marker of disease severity. There is no approved effective therapy for arthritis in SSc and immunosuppressive treatments are given to SSc patients by analogy with rheumatoid arthritis (RA), but with limited effect. The last few years have revolutionized the understanding of the pathogenesis of RA by deciphering the heterogeneity of synovium at both the cellular and molecular levels. Nevertheless, the pathogenesis of joint involvement in SSc remains largely unknown.

Objectives

To characterize the synovium in SSc at tissue and cellular levels and to compare it with RA synovium.

Methods

Nine consecutive patients fulfilling SSc classification criteria and having joint synovitis were included. Patients with overlap with other autoimmune rheumatic diseases were excluded. Synovial tissues (8 wrists, 1 knee) were obtained by ultrasound-guided biopsy and were compared to those obtained from five RF and CCP positive RA patients (3 wrists, 3 knees). Tolerance of the procedure was assessed after 3-5 days. Histological analysis of the synovium determined the Krenn synovitis score (0-9) and stratified the synovial tissue according to previously published histological features1. One biopsy, without synovial tissue, was not processed further. ScRNA-seq libraries were prepared with 10X Genomics technology and sequenced on NovaSeq 6000. Integrated bioinformatics analysis used Cell Ranger and Seurat software. Overexpressed genes were selected using log2 ratio (>0.25) and false discovery rate adjusted p value (< 0.05). For pathway enrichment analysis, Enrichr software was used.

Results

Of the nine SSc-patients, 6 were women, median age was 65 [IQR: 58-67] years, median disease duration was 2 [0.5-5] years and 2 had diffuse cutaneous subtype. The antibody status was as follows: anti-Scl70 (2), anti-centromere (2), anti-RNA polymerase III (3), anti-Ku (1) and isolated ANA (1). In the RA cohort, 4/5 were women, median age was 56 [54-59] years and median disease duration 6.5 [5-7.5] years. Synovial biopsy was well-tolerated by all the patients. Krenn synovitis score was lower in SSc as compared to RA across the three components of the synovitis score (lining layer, stroma and inflammatory infiltrate). In SSc, 7/8 (87.5%) biopsies were characterized by a pauci-immune pathotype, whereas in RA 3/6 (50%) were pauci-immune. Due to the low inflammatory pauci-immune pathotype in all but one SSc patients, we focused the scRNA sequencing analysis on synovial fibroblasts (SF) (number of SF studied: 4876 in SSc and 5885 in RA). We identified four clusters of SF with respective marker genes: SF1 (CXCL12, APOE, RARRES2, CCL2), SF2 (PRG4, MMP1, MMP3, CD55), SF3 (POSTN, ASPN, COMP, COL1A1) and SF4 (FN1, TIMP1, SERPIN2, PRELP). Comparison between SSc and RA SF subtypes showed differences in the proportion of the clusters between both diseases with higher enrichment of SF2 corresponding to the lining SF in SSc. 741 genes were differentially expressed between SSc and RA SF with 414 genes overexpressed in SSc SF. Pathway enrichment analysis of these 414 genes identified TGF-β (p.adj: 3.708e-18) and interferon (p.adj: 1.071e-8) signaling pathways. TGF-β signaling was enriched across all the clusters of SF, whereas interferon signaling mostly in sublining SF. The most overexpressed genes in SSc included PLCG2 (encoding the signaling enzyme PLCγ2, which plays a regulatory role in various immune pathways), PCOLCE2 (encoding a procollagen C-endopeptidase enhancer) and the transcription factor AHR (negative regulator of TGF-β).

Conclusion

Synovitis in SSc differs from RA synovitis both at histological and molecular levels. By highlighting the low inflammatory nature of the synovium and the enrichment in TGF-β and interferon signaling pathways in SSc SF, our study questions the use of the same immunosuppressive therapies in RA and SSc. These results are the basis for the development of specific targeted therapies for arthritis in SSc.

References

[1]Humby F, et al. Ann Rheum Dis 2019;78:761–72.

Disclosure of Interests

Miranda Houtman: None declared, Raphael Micheroli: None declared, Kristina Bürki: None declared, Chantal Pauli: None declared, Sam G. Edalat: None declared, Mojca Frank Bertoncelj: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur.

Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Caroline Ospelt: None declared, Muriel Elhai Speakers bureau: BMS.

No evidence for an effect of the first COVID-19 lockdown on work stress conditions in office workers

Background

The COVID-19 pandemic has forced around 50 % of employees of Switzerland into a working from home setting during March and April 2020. Working from home appears to change the work experience of office workers considerably. The aim of this analysis was to investigate the effect of the first COVID-19 lockdown on work stress conditions.

Methods

We based this longitudinal analysis on control group data from an ongoing stepped-wedge cluster randomized controlled trial. Office workers from two Swiss organizations, aged 18-65 years, were included. Baseline data from January 2020 (before the COVID-19 pandemic) were compared with follow-up data collected during the fourth and fifth week of the first lockdown (April 2020). Work stress conditions were measured using the Job-Stress-Index (JSI). The JSI indicates the ratio of work-related resources (e.g., appreciation at work) and stressors (e.g., work organisation) on a scale from 0 (stressors < resources) to 100 (stressors > resources). Paired sample t-tests were performed for statistical analysis.

Results

Data from 75 participants were analysed. Fifty-three participants were female (70.7 %). The mean age was 42.8 years (range from 21.8 to 62.7) at baseline. At baseline, the mean JSI was 47.6 (SD = 5.0), with 77.7 (SD = 12.4) for resources and 22.3 (SD = 10.1) for stressors. At follow-up, the mean JSI was 47.4 SD = 4.5), with 77.5 (SD = 11.7) for resources and 21.4 (SD = 9.6) for stressors. We found no evidence for a difference in JSI (estimate = 0.67, 95 % CI: -0.33 to 0.66, p-value = 0.50), its index of resources (estimate = 0.23, 95 % CI: -1.32 to 1.69, p-value = 0.82) or the index of work stressors (estimate = 1.4, 95 % CI: -0.32 to 2.02, p-value = 0.15) between measurement time points.

Conclusions

The first COVID-19 lockdown did not result in a difference of work stress conditions among our sample of Swiss office workers. Improved working times and work-life balance may have contributed to this finding.

Key messages

Improved working times and work-life balance may have contributed to stable task-related stressors and resources in the early phase of the lockdown.

Other, non-work-related environmental stressors should be investigated to explain COVID-19-related changes in mental and physical health.

Sex-specific difference in cardiac function in patients with systemic sclerosis: association with cardiovascular outcomes

Background

Cardiac involvement is an important cause of hospitalization and mortality in patients with systemic sclerosis (SSc) and advanced echocardiographic measures such as left ventricular (LV) global longitudinal strain (GLS) have already demonstrated to improve risk-stratification. However, possible sex differences in echocardiographic parameters including LV GLS have not been explored so far.

Purpose

To compare standard and advanced echocardiographic parameters between men and women with SSc and evaluate their association with cardiovascular outcomes.

Methods

A total of 746 SSc patients from four different centers were included of which 628 (84%, 54±13 years) women and 118 (16%, 55±15 years) men. Baseline transthoracic echocardiographic (TTE) data with standard and advanced (LV GLS) measurements as well as clinical characteristics were analysed. The study endpoint was the composite of all-cause mortality and cardiovascular hospitalisations.

Results

Men and women showed several differences in terms of disease characteristics: greater modified Rodnan skin score, higher prevalence of diffuse cutaneous SSc, lung fibrosis and myositis, more impaired pulmonary function (DLCO) and higher creatine phosphokinase were observed in men, while women were characterized by longer disease duration, higher NT-proBNP and lower glomerular filtration rate. By TTE, men showed larger LV indexed volumes, lower LV ejection fraction and more impaired LV GLS [−19% (IQR −20% to −17%) vs. −21% (IQR: −22% to −19%, p&lt;0.001)]. Considering the significant differences in clinical characteristics between men and women, a propensity matching score was applied to explore whether sex-differences in TTE parameters were maintained. The matching was performed according to age, disease duration, presence of diffuse SSc, lung fibrosis, DLCO and NT-proBNP (n=140); after matching, LV GLS still showed significant difference between men and women [−19% (IQR −20% to −18%) vs. −20% (IQR −22% to −18%, p=0.03)] while LV volumes and ejection fraction did not. After a median follow-up of 48 months (IQR: 26–80), the combined endpoint occurred in 182 patients and Kaplan-Meier survival analysis (Figure) showed that men experienced higher cumulative event rates as compared to women (Chi-square 8.648; Log rank 0.003) even after matching for clinical characteristics (Chi-square 7.211; Log rank 0.007); however, sex difference in outcomes was neutralized after matching groups according to LV GLS. Furthermore, LV GLS showed a significant association with prognosis in the overall group (HR: 1.173; 95% CI: 1.106–1.244, p&lt;0.001) without significant interaction with sex (p=0.373), indicating a consistent prognostic value of LVGLS for both men and women.

Conclusions

Among patients with SSc, LV GLS is more impaired in men as compared to women even after matching for clinical characteristics, and its impairment is associated with higher prevalence of death and cardiovascular hospitalization.

Funding Acknowledgement

Type of funding sources: None.

ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part III: Pharmacology, medical and surgical management of post-transplant extrapulmonary conditions statements

Patients with connective tissues disease (CTD) are often on immunomodulatory agents before lung transplantation (LTx). Till now, there's no consensus on the safety of using these agents perioperative and post-transplant. The International Society for Heart and Lung Transplantation-supported consensus document on LTx in patients with CTD addresses the risk and contraindications of perioperative and post-transplant management of the biologic disease-modifying antirheumatic drugs (bDMARD), kinase inhibitor DMARD, and biologic agents used for LTx candidates with underlying CTD, and the recommendations and management of non-gastrointestinal extrapulmonary manifestations, and esophageal disorders by medical and surgical approaches for CTD transplant recipients.

Diffuse myocardial fibrosis precedes impairment of myocardial strain in patients with systemic sclerosis

Funding Acknowledgements

Type of funding sources: None.

Background - Myocardial involvement is common in patients with systemic sclerosis (SSc) and causes myocardial fibrosis and subtle ventricular dysfunction. However, the temporal onset of myocardial involvement during the progression of the disease is yet unknown.

Purpose - To investigated the presence of subclinical functional impairment and diffuse myocardial fibrosis in patients with very early diagnosis of SSc (VEDOSS) and to compared the findings to patients with established SSc and healthy controls.

Methods - 110 SSc patients (86 with established SSc and 24 with VEDOSS) and 15 healthy controls were prospectively recruited. The study subjects underwent cardiovascular magnetic resonance on a clinical 1.5T system. Pre- and post-contrast T1 mapping was performed using a MOLLI (Modified Look-Locker Inversion Recovery) sequence. For extracellular volume (ECV) measurements, a single bolus protocol with image acquisition 15-20 min. post-contrast injection was used. For the assessment of subtle functional impairment, global longitudinal (GLS) and circumferential (GCS) myocardial strain were evaluated.

Results - Native T1 values and ECV were elevated in VEDOSS and in patients with established SSc compared to controls (p &lt; 0.001; Figure 1 A & B). GLS was similar in VEDOSS and controls but significantly reduced in patients with established SSc (p &lt; 0.001; Figure 1 C). GCS was similar over all groups (p = 0.88). Patients with clinical evidence of pulmonary or gastrointestinal involvement had higher ECV or T1 values, respectively. Patients with clinical signs of cardiac involvement had lower absolute GLS. SSc subtype, classification or disease duration were not associated with the extent of myocardial fibrosis or impaired strain.

Conclusion - Subclinical myocardial involvement first manifests as diffuse myocardial fibrosis identified by expansion of ECV and increased native T1 in VEDOSS patients while subtle functional impairment as measured by GLS only occurs in established SSc. No single clinical feature of SSc shows a strong association with subtle myocardial involvement.

Pro-fibrotic phenotype of bone marrow stromal cells in Modic type 1 changes

Modic type 1 changes (MC1) are painful vertebral bone marrow lesions frequently found in patients suffering from chronic low-back pain. Marrow fibrosis is a hallmark of MC1. Bone marrow stromal cells (BMSCs) are key players in other fibrotic bone marrow pathologies, yet their role in MC1 is unknown. The present study aimed to characterise MC1 BMSCs and hypothesised a pro-fibrotic role of BMSCs in MC1. BMSCs were isolated from patients undergoing lumbar spinal fusion from MC1 and adjacent control vertebrae. Frequency of colony-forming unit fibroblast (CFU-F), expression of stem cell surface markers, differentiation capacity, transcriptome, matrix adhesion, cell contractility as well as expression of pro-collagen type I alpha 1, α-smooth muscle actin, integrins and focal adhesion kinase (FAK) were compared. More CFU-F and increased expression of C-X-C-motif-chemokine 12 were found in MC1 BMSCs, possibly indicating overrepresentation of a perisinusoidal BMSC population. RNA sequencing analysis showed enrichment in extracellular matrix proteins and fibrosis-related signalling genes. Increases in pro-collagen type I alpha 1 expression, cell adhesion, cell contractility and phosphorylation of FAK provided further evidence for their pro-fibrotic phenotype. Moreover, a leptin receptor high expressing (LEPRhigh) BMSC population was identified that differentiated under transforming growth factor beta 1 stimulation into myofibroblasts in MC1 but not in control BMSCs. In conclusion, pro-fibrotic changes in MC1 BMSCs and a LEPRhigh MC1 BMSC subpopulation susceptible to myofibroblast differentiation were found. Fibrosis is a hallmark of MC1 and a potential therapeutic target. A causal link between the pro-fibrotic phenotype and clinical characteristics needs to be demonstrated.